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ICONOGRAMS 


ICONOGRAMS 

A  Collection  of  Coloi-fd    I'l.-ites 

From 

Prof.  BOCKENHEIMER'S 

Atlas   dkr   Chirurgischkn    Haltkrankhkiten" 
ILLUSTRATING 

Interesting  Surgical  Conditions 


EXPLANATORY  TEXT 

WITH 

Special  Reference  to  Diagnosis  and  Treatment 

ADAPTED    AND    REVISED    IIV 

FAXTON    E.   GARDNER,   M.D. 

Lecturer  in  the 
New  York  Polyclinic  Medical  School,  etc. 


NEW   YORK 

REBMAN    COMPANY 

HERALD  SQUARE  BUILDING 
lU-145    WEST    3Gin    STREET 


Copyright  by  Rebman  Company,  1913 
New  York 


All  rights  reserved 


Gil 
6l 


FOREWORD. 

This  Atlas  is  not  a  text  book,  still  less  a  series  of  extensive  mono- 
graphs. 

No  claim  is  made  that  any  subject  has  been  exhaustively  covered. 

The  sole  aim  of  the  text  is  to  set  forth,  in  as  concise  a  form  as  pos- 
sible, the  essentials  of  diagnosis  and  treatment,  and,  by  comparison 
with  the  plates  themselves,  to  establish  in  the  reader's  mind  an  asso- 
ciation between  the  objective  aspect  of  a  condition  and  the  two  points 
just  referred  to — which  association  cannot  but  be  helpful  when  a  simi- 
lar case  occurs  in  actual  practice. 

As  a  basis  the  plates  in  Bockenheimer's  Atlas  of  Clinical  Surgery 
have  been  used.  The  order  of  the  plates  has  not  been  changed.  Con- 
siderable thought  was,  however,  devoted  to  this  point.  At  first  it  was 
believed  that  another  grouping  of  the  figures  (by  anatomical  regions, 
for  instance)  might  prove  more  didactic  and  thus  enhance  the  practi- 
cal value  of  the  book,  but,  after  several  attempts,  it  was  found  that  no 
arrangement  was  perfect — each  one  proved  artificial  in  some  respects 
and  had  its  drawbacks  as  well  as  its  advantages.  The  idea  was  then 
abandoned. 

The  text  has  been  completely  remodelled.  Things  move  rapidly 
nowadays  in  medicine.  There  is  no  subject  on  which  the  past  five  or 
six  years  have  not  brought  some  enlightenment;  a  few  have,  indeed, 
been  absolutely  revolutionized.  The  rewriting  has  been  done  from  the 
standpoint  of  American  methods,  reference  to  which  is,  unfortunately, 
very  scant  in  most  Continental  treatises. 

No  theorizing  has  been  indulged  in,  except  when  a  direct  relation 
to  diagnostic  or  therapeutic  principles  was  involved. 

In  a  book  of  this  kind,  comparison  of  different  plates  with  each 
other  is  always  very  fruitful.  This  is  the  reason  why  all  references  to 
plates  have  been  printed  in  bold  type,  by  which  means  their  im- 
portance is  clearly  and  duly  emphasized. 


CONTKXTS 

TUMORS.    Figs.  1  to  54. 

CARCINOIMA.    Figs.  1  to  23.  pace 

Fig.  1.  Rodeut  ulcer -^ 

Fig.  2.  Carcinoma  of  the  skin  of  the  forehead.      ...  5 

Fig.  3.  Carcinoma  of  the  lip ^ 

Fig.  4.  Carcinoma  of  the  nose 6 

Fig.  5.  Cai'ciuoma  of  the  lip  and  lupus 9 

Fig.  6.  Papilloma  of  the  tongue 10 

Fig.  7.  Papilloma  and  carcinoma  of  the  tongue.     ...  10 

Fig.  8.  Carcinoma  and  leucoplakia  of  the  tongue.     .      .  10 

Fig.  9.  Ulcerated  carcinoma  of  the  tongue 10 

Fig.  10.  Carcinoma  of  the  hreast 18 

Fig.  11.  Carcinoma  of  the  male  hreast.    .  • 18 

Fig.  12.  Carcinoma  of  the  nipple 18 

Fig.  13.  P.iget's  disease 19 

Fig.  14.  Cancer  "en  cuirasse." 19 

Fig.  15.  Cancer  "en  cuii-asse." 19 

Fig.  16.  Carcinoma  mastitoides 20 

Fig.  17.  Carcinoma   of  the   scalp 20 

Fig.  18.  Carcinoma  of  the  scalp.    Sebaceous  cysts.     .      .  21 

Fig.  19.  Carcinoma  of  the  penis 22 

Fig.  20.  Carcinoma  of  the  skin  of  the  leg  (burn).     .      .  24 

Fig.  21.  Carcinoma  of  the  hand  (wart) 24 

Fig.  22.  Carcinoma  of  the  hand  (scar) 24 

Fiff.  23.  Melanotic  cnrcinoinn 25 


SARCOMA.    Figs.  24  to  35. 

Fig.  24.  Lymphosarcoma  of  the  neck 
Fig.  25.  Epii)haryngeal  sarcoma.  . 
Fig.  26.  Angiosarcoma  of  the  cheek 
Fig.  27.  Sarcoma  of  the   face.     . 
Fig.  28.  ^lelanosarcoma  of  the  scalp 
Fig.  29.  Sarcoma  of  the  breast.     . 
Fig.  30.  Cystosarcoma  of  the  breast 
Fig.  31.  Multiple  sarcoma  of  the  skin 
vii 


30 
32 
35 
36 
36 
33 
38 
38 


PAGE 

Fig.  32.  Sarcoma  of  the  linmerus 40 

Fig.  33.  Sarcoma  of  the  forearm 44 

Fig.  34.  Chondromyxosarcoma 45 

Fig.  35.  Epulis 46 

MIXED  AND  BENIGN  TUMORS.    Figs.  36  to  54. 

Fig.  36.  Angioma  of  the  tongnie 47 

Fig.  37.  Cystic  fibroadenoma  of  the  breast 48 

Fig.  38.  Cutaneous  horn.     Adenoma  sebaceum.     ...  50 

Fig.  39.  Endothelioma  of  the  face 51 

Fig.  40.  Mixed  tumor  of  the  parotid 53 

Fig.  41.  Carpal  ' '  ganglion. " 55 

Fig.  42.  Acute    purulent    bursitis 56 

Fig.  43.  Hygroma 56 

Fig.  44.  Cystic  goiter 58 

Fig.  45.  Papilloma  of  the  skin 61 

Fig.  46.  Dermoid  cyst  of  the  forehead 62 

Fig.  47.  Dermoid  cyst  of  the  prepuce 62 

Fig.  48.  Dermoid  cyst  of  the  neck 62 

Fig.  49.  Fibroma  of  the  sheath  of  a  tendon 64 

Fig.  50.  Multiple  chondroma  of  the  fingers.     .      .      .     -.  66 

Fig.  51.  Hemorrhoids 67 

Fig.  52.  Fibrolipoma 68 

Fig.  53.  Subcutaneous  lipoma 69 

Fig.  54.  Symmetrical  lipomata 69 


MISCELLANEOUS  LESIONS.    Figs.  55  to  83. 
SCABS  AND  FISTULJE. 

Fig.  55.  Granulating  wound  and  epidermic  grafts.     .      .  75 

Fig.  56.  Fistula  due  to  insufficient  drainage 75 

Fig.  57.  Congenital  fistula  of  the  neck 76 

Fig.  58.  Keloid  after  vaccination 79 

Fig.  59.  Keloid  after  laparotomy 79 

MUSCULAE  CONTEACTIONS  AND  BONY  DEFORMITIES. 

Fig.  60.  Dupuytren's  contraction 81' 

Fig.  61.  Cicatricial  retraction  of  finger 82 

Fig.  62.  Ulnar    "claw    hand." 82 

viii 


PAOE 

Fig.  63.  Isehemic  retraction  of  iiinsclos  of  tlio  foro:inii.     .  82 

Fig.  ()4.  Hallux  valgus  and  lianuner  toe 87 

Fig.  65.  Racliitis 88 

Fig.  66.  Pseudarthrosis 90 

N.'EVI,  VASCULAR  AND  LYML'HATIV  LESIONS. 

Fig.  67.  Pigmentary  n;T3Vus 9" 

Fig.  68.  Pigmented  niisvus  and  neurofilironiatosis.        .      .  92 

Fig.  69.  Neurolibroinatosis  of  the  seal)) 92 

Fig.  70.  Acne  rosacea   and  rliinopliyiua 95 

Fig.  71.  Elephantiasis    of   tlu'    ])enis 96 

Fig.  72.  Elephantiasis  of  the  fnot  and  varicose  ulcer.     .  97 

Fig.  73.  Detachment   of  the   skin 99 

Fig.  74.  Othematoma 99 

Fig.  75.  Cutaneous  angioma 101 

Pig.  76.  Vascular  nixivus 101- 

Fig.  77.  Spontaneous  hemorrhages.    Hemophilia.  .      .      .  104 

Fig.  78.  Gunshot  injury  of  the  arm 106 

Fig.  79.  Traumatic    asphyxia 107 

Fig.  80.  Cavernous  angioma 101 

Fig.  81.  Cutaneous  and  subcutaneous  angioma.     .      .      .  101 

Fig.  82.  Arterial  aneurysm 108 

Fig.  83.  Varices  of  the  leg HI 


INFECTIONS.    Figs.  84  to  131. 

ACUTE  PYOGENIC  PROCESSES.    Figs.  84  to  114. 

Fig.  84.  Acute  purulent  thrombo-phlebiti; 
Fig.  85.  Subcutaneous  abscess  of  the  breast 

Fig.  86.  Puerperal  mastitis 

Fig.  87.  Furuncle 

Fig.  88.  Furunculosis 

Fig.  89.  Carbuncle 

Fig.  90.  Erysipelas  of  the  face.     . 

Fig.  91.  Hemorrhagic  bullous  erysipelas. 

Fig.  92.  Erysipeloid 

Fig.  93.  Subepidermic  whitlow.     . 
Fig.  94.  Subcutaneous  whitlow.     . 
Fig.  95.  Osteal  and  articular  whitlow. 
ix 


122 
123 
124 
125 
125 
125 
129 
131 
133 
133 
133 
134 


PAGE 


Fig.  96.  Tendon-sheath    suppuration 1.34 

Fig.  97.  Interdigital    whitlow 135 

Fig.  98.  Paronycliia 138 

Fig.  99.  Ingrowing  toe  nail ,     .      .      .   139 

Fig.  100.  Corns    and    bunions 140 

Fig.  101.  Gangrenous  phlegmon 141 

Fig.  102.  Acute  suppurative  cervical  adenitis.  .  .  .  143 
Fig.  103.  Purulent  alveolar  periostitis  of  the  lower  jaw.  145 
Fig.  104.  Chronic  osteomyelitis  of  the  lower  jaw.  .  .  154 
Fig.  105.  Acute  osteomyelitis  of  the  scapula.  .  .  .  155 
Fig.  106.  Chronic  osteomyelitis  of  the  humerus.  .  .  .  155 
Fig.  107.  Acute  osteomyelitis  of  the  tibia.    Total  necrosis 

of  the  dia]3hysis 156 

Fig.  108.  Generalized  infection .157 

Fig.  109.  Gaseous  gangrene 163 

Fig.  110.  Bubo 166 

Fig.  111.  Gonorrheal  arthritis  of  the  wrist.     .      .      .      .   168 

Fig.  112.  Malig-nant  pustule    (early   stage) 172 

Fig.  113.  The  same  (later  stage) 172 

Fig.  114.  Cervical    adenitis 174 

CHRONIC  INFECTIONS.    Figs.  115  to  131. 

Fig.  115.  Actinomycosis  of  the  cheek 175 

Fig.  116.  Actinomycosis  of  the  neck. 175 

Fig.  117.  Marginal  glossitis 177 

SYPHILIS. 

Fig.  118.  Syphilitic  chancre  of  the  tongue 178 

Fig.  119.  Gumma   of    the    tongaie 182 

Fig.  120.  Gummatous  ulcer 181 

Fig.  121.  Gummatous  abscess. 181 

Fig.  122.  Gummatous   osteitis 182 

Fig.  123.  Gummatous  ulcer 181 

TUBERCULOSIS. 

Fig.  124.  Tuberculous  cervical  adenitis 192 

Fig.  125.  Multiple  tuberculosis  of  joints 199 

Fig.  126.  Purulent  tuberculous  arthritis.     .      .      .      .      .  199 

Fig.  127.  Fibrous  arthritis.     Ankylosis 200 

Fig.  128.  White  swelling  of  the  knee 200 

X 


PAGE 

Fig.  J  29.  Tuherculosis  of  the  testicle 202 

Fig.  L'!0.  Tuherfulo.sis    of    the    hand 201 

Fig.  I'M.  S|)ina  veiitosa 201 


GANGRENES.    BURNS.      Figs.  132  to  141. 

Fig.  132.  Moist  gangrene  of  tlie  foot 209 

Fig.  133.  Dry  gangrene  of  tlie   arm 209 

Fig.  134.  Gangrene  of  the  skin  and  fascia 209 

Fig.  135.  Carbolic  gangrene 211 

Fig.  136.  Burns 217 

Fig.  137.  Frostbite 220 

Fig.  138.  X-ray  burn 219 

Fig.  139.  Perforating  nicer.     R.^yxaud's    disease.     .      .   215 

Fig.  140.  Diabetic  gangrene 212 

Fig.  141.  Gouty  arthritis 222 


MALFORMATIONS.     Figs.  142  to  150. 

Fig.  142.  Eucephalocele  and  rachischisis 227 

Fig.  143.  Spina  bifida.    Myelocele 229 

Fig.  144.  Spina    bifida.     Myelocystocele 230 

Fig.  145.  Multiple  congenital  cystic  lymphangioma.     .     .  235 

Fig.  146.  Teratoma  of  the  face 237 

Fig.  147.  Persistency  of  the  omphalo-mesenteric  duct..  239 

Fig.  148.  Fetal   umbilical  hernia 240 

Fig.  149.  Amniotic  constrictions  of  the  fingers.     .      .      .  242 

Fig.  150.  Acromegaly 242 


TUMORS 

Figs.  1-54 


A.— Carcinoma— Figs.  1-23 

B.— Sarcoma— Figs.  24-35 

C— Mixed  and  Benign  Tumors — Figs.  36-54 


Bockenheimer,  Atlas. 


Tab.  I. 


U 


U 


Rebman  Company,  New-York. 


CARCINOMA 

Figs.  1   to  5,   inclusive,  depict  types  of  cutaneous  carcinoma 
affecting  the  face. 

Cancers  of  the  face  are  of  great  importance,  because  of  their 
frequency.  The  nose,  eyelids,  cheeks,  temples  and  forehead  are  the 
most  common  sites,  while  the  chin  and  ears  are  least  affected.  In 
youth,  these  tumors  are  very  rare ;  when  they  occur,  they  are  malig- 
nant degenerations  of  a  xeroderma  pig-mentosum  (a  disease  described 
by  Kaposi,  and  developing  in  the  first  years  of  life;  characterized 
by  multiple  pigmentary  spots  on  the  parts  exposed  to  sunlight,  and 
atrophy  of  the  skin.  Epitheliomatous  degeneration  is  common).  In 
older  people  (fortieth  to  seventieth  years),  cutaneous  carcinoma  of 
the  face  is  frequent  and  develops  from  pre-existing  warts,  cutaneous 
horns,  adenomata  {see  Fig.  38),  dermoid  or  sebaceous  cysts  (for  a 
similar  condition  originating  in  a  wen,  see  Fig.  18),  or  on  a  ground 
prepared  by  chronic  irritations  of  the  skin  (erysipelas,  eczema,  sebor- 
rhea, excessive  exposure  to  rough  weather,  sailor's  skin). 

In  old  country  people  the  flat  carcinoma,  of  the  types  shown  in 
Figs.  1  and  2,  is  of  common  observation,  being,  as  it  is,  favored  in  its 
development  by  early  wrinkling  of  the  skin,  uncleanliness  and  senile 
seborrhea,  causing  an  accumulation  of  dirty  scales  on  the  skin.  When 
these  epidermic  scales  are  scratched,  superficial,  easily  bleeding  sores 
are  formed,  which,  however,  heal  quicklj^  as  long  as  they  are  not 
cancerous. 


Fig.  1  shows  a  so-called  "Rodent  ulcer,"  that  is,  a  flat,  very 
superficial,  cutaneous  cancer,  in  a  tyjiical  situation  on  the  face;  still 
clear  of  the  subjacent  tissues.  Rodent  ulcer,  which,  of  course,  may  be 
observed  not  only  on  the  face,  but  in  any  point  of  the  skin,  presents 
itself  at  first  as  a  hard,  flat,  reddisli  nodule  wliich,  when  scratched  or 
broken,  forms  a  shallow  ulcer  with  little  tendency  to  heal.  Of  slow 
growth,  and  never  attaining  a  conspicuous  size  before  several,  and 
often  many,  years,  it  generally  remains  a  long  time  unnoticed  by  the 
patient,  especially  as  it  causes  no  inconvenience  or  pain.  Wlien  it 
presents  itself  as  a  growing  superficial  ulceration,  this  usually  has 
a   circular  shape  with  hard,  slightly  raised  edges  of  overlapping 

3 


thinned  epidermis ;  while  the  floor  of  the  ulcer  is,  for  the  most  part, 
soft  at  first,  and  the  whole  growth  is  movable  over  the  deeper 
structures. 

It  is  characteristic  of  these  cutaneous  carcinomata  that  plugs  the 
size  of  a  pin's  head  can  be  squeezed  from  the  yellow  surface  of  the 
ulcer ;  microscopic  examination  shows  these  to  consist  of  broken-down, 
fatty,  cancer  cells.  The  ulcer  is  often  covered  by  a  scab,  so  that  the 
diagnosis  is  only  possible  after  its  removal.  As  the  tumor  extends 
there  appear  radiating  contractions  of  the  surrounding  skin  and  con- 
sequent deformity  (of  the  eyelids,  for  example).  The  original  circular 
shape  is  then  often  lost,  and  the  outline  becomes  irregular  (Fig.  2). 

At  first  superficial,  the  tumor  may  after  some  years  extend  to  the 
deeper  parts  and  cause  extensive  destruction;  for  instance,  of  the 
bones  of  the  face  (Fig.  4).  This  deep  extension  is  especially  seen  in 
parts  where  the  subcutaneous  fatty  tissue  is  not  developed  (the  tem- 
ples, bridge  of  the  nose  and  zygomatic  arch,  etc..  Figs.  2  and  4) ; 
and  it  is  also  evidenced  from  the  beginning  by  the  decrease  in  mobility 
of  the  tumor  over  the  subjacent  structures.  However,  the  tendency 
to  deep  extension  is  very  little  marked :  but  the  extension  in  surface 
is  practically  unlimited,  old  ulcers  sometimes  attaining  a  huge  size. 

On  account  of  the  spontaneous  cicatrization,  which  may  take  place 
at  different  parts  of  the  ulcer  or  over  its  whole  surface,  although  it  is 
not  permanent,  these  growths  were  formerly  wrongly  placed  in  the 
group  of  benign  tumors  under  the  name  of  cancroid.  Certainly 
metastases  are  by  no  means  as  frequent  as  in  other  cancers;  the  gen- 
eral condition  of  the  patient  for  years  remains  unimpaired  while  the 
ulcer  is  but  slowly  expanding;  recurrence  seldom  takes  place  after 
complete  removal ;  so  that,  as  a  rule,  ulcus  rodens  is  not  possessed  of 
the  high  malignancy  of  the  cancers  of  mucous  membranes  and  glandu- 
lar organs.  It  is,  however,  an  unquestionably  malignant  lesion.  Its 
microscopic  structure  is  that  of  baso-cellular  epithelial  cancer. 


The  appearance  of  rodent  ulcer  is  typical  and,  oftentimes,  the 
diagnosis  is  not  difficult,  provided  care  is  taken  thoroughly  to  remove 
the  overlying  scab  to  bare  the  real  surface  with  its  slightly  raised 
and  everted  epidermic  edge.  However,  particularly  in  the  region 
of  the  chin,  an  extragenital  syphilitic  chancre,  especially  if 
modified  by  local  caustic  applications,  might  show  a  certain  resem- 
blance, but  the  early  adenitis  and  the  demonstration  of  the  spirochetse 
pallidse  would  clear  up  the  doubt.    A  tertiary  gumma  or  an  atypical 


lupus  iniglit  also  be  mistaken  for  a  rodent  ulcer.  The  notion  of  age 
is  very  important,  ulcus  rodens  being  a  disease  of  elderly  people.  In 
all  doubtful  cases,  microscopical  examination  of  an  excised  fragment 
is  the  quickest  and  best  way  to  settle  the  question. 

Transient  epidermization  can  generally  be  promptly  obtained  in 
small  flat  ulcers  by  antiseptic  dressings.  A  permanent  healing  is, 
however,  not  to  be  obtained  by  this  means,  ;mil  under  the  scar, 
columns  of  epithelial  cells  keep  on  proliferating. 

Treatment 

Early  excision,  about  half  an  inch  beyond  the  ulcer  in  healthy 
tissues,  and  of  suflicient  depth,  is  the  treatment  preferred  and  almost 
exclusively  advocated  by  uuiuy  surgeons;  and  was  in  fact,  success- 
fully applied  in  the  case  shown  in  Fig.  1.  The  defect  was  repaired 
by  a  pedunculated  flap  taken  from  the  left  side  of  the  forehead, 
where  the  loss  of  substance  was  covered  with  Thiersch  grafts. 

Rodent  ulcers  are  frequently  situated  in  the  vicinity  of  structures 
important  to  consider  for  cosmetic  results  (eyelids,  nose) :  the  gap 
created  by  the  surgeon  is  often  surprisingly  large,  owing  to  the  ten- 
dency rodent  ulcers  seem  to  have  to  draw  tissues  toward  them,  so 
that  a  plastic  repair  is  by  no  means  a  simple  task  in  many  cases.  This 
is  why  many  dermatologists  prefer  treatment  by  scraping  with  the 
sharp  spoon,  followed  by  cauterization  with  acid  nitrate  of  mercury, 
and  subsequent  applications  of  X-rays.  Such  a  treatment  gives  excel- 
lent results  {She r well)  provided  it  be  very  thorough.  If  incom- 
plete, it  simply  accelerates  the  progression  of  the  ulcer.  It  can  be 
carried  out  under  local  anesthesia.  Good  results  have  been  reported 
from  the  use  of  radium  (Abbe).  X-ray  treatment  alone  is  also  effi- 
cient, especially  the  single  dose  method  {Mackee)  in  which  the  ulcer- 
ative type  requires  about  1\\  Ilolzhnecht  units,  and  the  nodular  form 
iibout  114  of  the  same  units.  Finally,  caustic  pastes,  tabooed  by  sur- 
geons, have  given  favorable  results  in  the  hands  of  dermatologists 
{Robinson,  Pusey). 

Fig.  2  shows  an  advanced  carcinoma  of  the  skin  of  the  fore- 
head with  irregular  borders.  The  growth  has  already  extended  to  the 
bones.  The  upper  eyelid  and  the  ocular  conjunctiva  are  also  involved. 
This  is  a  case  of  the  rare  form  of  cancer  of  the  skin  first  described  by 
von  Bergmann,  which  in  its  early  stages  appears  in  the  form  of  small 
multiiile  nodules  and  may  therefore  be  mistaken  and  treated  for 
tuberculosis  cutis  (lui)us).    The  raised,  irregular,  hard  edges  of  the 

5 


Tilcer  point  to  the  correct  diagnosis,  wliich  in  doubtful  cases  should  be 
cleared  up  by  removal  of  a  piece  for  examination.  Previous  treatment 
with  X-rays  had  caused  a  rapid  extension  of  the  carcinoma,  so  that  the 
patient  came  to  the  clinic  in  an  inoperable  condition.  When  carcinoma 
of  the  face  extends  through  to  the  dura  mater,  the  patient  may  die  of 
meningitis ;  operation  is  contraindicated  and  the  palliative  treatment 
alone  comes  under  consideration.  This  treatment  consists  in  disin- 
fection by  antiseptic  dressings  with  potassium  permanganate  and 
hydrogen  peroxide.  Later  on,  cauterization  with  the  actual  cautery,. 
or  cautious  fulguration  (sparking  with  the  high  frequency  current) 
may  make  the  condition  less  unbearable  for  a  time. 

Fig.  4  shows  a  cutaneous  cancer  with  extensive  deep  growth,  hav- 
ing destroyed  the  bony  framework  of  the  nose  and  the  ethmoid  cells. 
This  form  of  cancer  in  its  early  stage  consists  of  subcutaneous  nodules 
covered  by  unaltered  skin.  The  skin  gives  way  when  the  nodules 
break  down  and  a  very  extensive  and  deep  cancerous  ulcer  results. 
This  may  be  mistaken  for  a  gumma,  but  the  latter  is  not  so  ragged 
and  has  a  yellow  core.  (Cf.  Fig.  120.)  The  presence  of  epithelial 
plugs  is  also  characteristic  of  this  form  of  carcinoma.  Microscopical 
examination,  the  Wassermann  reaction  and  antisyphilitic  salvarsan 
treatment  will  decide  the  diagnosis  in  doubtful  eases.  The  papilloma- 
tous forms  (Fig.  4),  which  often  give  rise  to  deep  cutaneous  cancer 
through  their  rapid  growth  and  metastatic  formations,  must  be  re- 
garded as  extremely  malignant  tumors. 

In  all  cases  of  extensive  carcinoma  of  the  face  the  patients  may  die- 
from  septic  pneumonia  when  the  destructive  process  reaches  the 
buccal  cavity. 

Permanent  results  may  sometimes  be  obtained  after  radical  opera- 
tions which  often  necessitate  removal  of  diseased  bones,  but  these 
of  course  are  very  disfiguring.  Inoperable  cases  may  be  somewhat 
relieved  by  the  palliative  treatment  already  mentioned. 

Fig.  3  shows  a  carcinoma  involving  the  whole  lower  lip. 

Cancers  of  the  lip  resemble  cancers  of  the  skin  in  form  and 
structure,  for  they  have  the  structure  of  squamous-celled  epithelioma 
and  tend  to  cornification.  Theirs  is  intermediate  between  the  com- 
paratively low  malignancy  of  cutaneous  cancer  and  that — very  high — 
of  lingual  carcinoma.  They  arise  as  cauliflower-shaped,  polypoid 
tumors  on  the  mucosa  of  the  lip  or  as  deep,  ragged  ulcers.  Both 
these  principal  varieties  are  found  in  cancers  of  all  mucous  raem- 


Bockeiilicimcr,  Atlas. 


Tab.  II. 


U 


RchiiKin  Company.  New-York. 


hr;iiios  cdvi'i-cd  with  ciiitlicliiiiii  (cliccks,  toiiniu',  jioiiis,  etc.).  This 
is  well  slmwii  ill  Fig.  3,  \\ln'i('  (l('c|)  ulcerations  alternate  witii 
|i;ipill()iii.il(iiis  growths.  In  sciiiic  p.-irts  llici'e  are  soal)s  on  tlie  surface 
of  tlie  ulcers;  in  others  isolated,  yellow,  epithelial  i)lu.u;s. 

CarcinoMiii  of  the  upper  lip  is  very  I'ai'c.  A  few  cases  have  heen 
IMlhlislu'd  ill  wiiicli  Mirh  ;i  c'l  l-cilKilii.-i  dc\'el(ipcd  al'icr  (Hie  of  the 
lower  lip,  in   a   syimiiet  rical    position. 

Carcinoma  of  the  lower  lip  is  almost  exclusively  a  disease  in  the 
male  sex,  and  seemingly  more  frerpient  in  smokers,  although  the  part 
played  by  tobacco,  admitted  by  a  iiia.jority  of  writers,  is  stoutly 
denie(l  liy   others. 

Labial  leucoplakia,  similar  to  that  observed  on  the  tongue 
{Cf.  Fig.  8),  and  closely  allied,  as  is  the  later,  to  syphilis  (see  page 
8),  may  degenerate  into  cancer.  Antecedent  tul)erculous  disease 
also  seems  to  be  a  cause  favoi'ing  the  development  of  cancer.  (Fig.  5 
is  an  example  of  this  mixed  condition.) 

Cancer  of  the  lower  lip  often  begins  at  the  junction  of  the  skin 
with  the  vermilion  border  of  the  lip,  generally  between  the  midline 
and  the  angle  of  the  mouth,  as  a  small,  hard  nodule  at  first  covered  by 
mucous  membrane.  The  latter  soon  becomes  broken  and  the  nodule 
grows,  infiltrating  the  surrounding  tissues  rapidly,  while  the  mucosa 
breaks  down  more  and  more,  and  thus  is  formed  an  ulcer.  The  whole 
of  the  lower  lip  may  be  gi-adually  destroyed  (Fig.  3)-  Scabs  and 
crusts  form  at  several  places  on  the  ulcer,  and  when  separated  cause 
bleeding. 

In  its  early  stages  the  cancer  is  only  an  ulcer  with  hard,  raised 
edges  and  a  crateriforni  floor,  but  later  ]iaiiillomatous  proliferations 
spring  from  this  floor  (Fig.  3).  The  more  the  carcinoma  extends, 
the  more  it  implicates  the  underlying  liones  and  the  mucosa  of  the 
cheeks  and  floor  of  the  mouth,  so  that  all  these  structures  may  be 
completely  destroyed.  The  exudation  of  growing  cancer  of  the  lip 
gives  rise  to  marked  cachexia,  gastritis  and  enteritis,  and  the  secre- 
tion maj^  reach  the  lungs  and  cause  death  from  septic  ]meumonia. 
In  such  inoperable  forms  the  submaxillary  and  submental  regions  are 
usually  lilleil  with  hard,  fixed  glands. 

UilJcnndal  Dkiynosis 

Although  these  advanced  runiis.  which  are  often  neglected,  espe- 
cially in  country  people,  are  umnistakable,  there  may  be  difficulty  in 
diagnosing  a  cancerous  nicer  in  the  early  stage,  when  it  is  most 
important.     The  irregular,  ragged  surface  of  tlie  carcinoma  is  in 

7 


marked  contrast  to  the  smooth,  raised  surface  of  a  primary  syphilitic 
sclerosis,  far  from  uncommon  on  the  lip.  The  comedo-like  epithelial 
plugs  which  are  pathognomonic  of  squamous-celled  epithelioma  can 
be  extruded  from  it  by  pressure.  The  submental  and  submaxillary 
glands  are  involved  early  in  both  cases,  and  as  there  are  no  character- 
istic clinical  symptoms  in  either  case  sufficient  to  differentiate  the 
adenitis,  scraping  of  the  surface  of  the  ulcer  and  a  dark  field  illumin- 
ator search  for  sinrocheUe,  or  the  excision  of  a  piece  of  the  tumor  for 
miscroscopical  examination,  are  imperative.  This  procedure  is  to  be 
preferred  to  a  test  course  of  antisyphilitic  treatment,  because  it 
wastes  no  time,  a  precious  advantage  when  dealing  with  malignant 
growths. 

An  ulcerated  gumma  of  the  lip  may  resemble  a  carcinomatous 
ulcer.  Here  also,  if  anamnesis  and  a  positive  Wassermann  reaction 
are  not  suthcient  to  clear  any  doubts,  histological  examination  must 
be  resorted  to.  The  difficulty  is  still  increased  by  the  close  relations 
between  syphilis,  leukoplakia  and  cancer  and  the  existence  of  hybrid 
forms.  In  a  general  way,  gummata  are  covered  with  a  special, 
tenacious,  yellowish  deposit  and  do  not  exhibit  the  hardness  of 
cancerous  formations. 

Primary  tuberculosis  of  the  lip,  or  the  extension  of  a  tuberculous 
ulcer  of  the  buccal  or  lingual  mucosa,  is  rare  on  the  lip.  The  irregu- 
lar edges  are  not  raised  and  remain  soft.  The  surface  of  the  ulcer 
has  the  anemic,  reddish-gray  color  of  all  tuberculous  ulcers;  and  at 
the  periphery,  there  maybe  some  small,  non-ulcerated  tubercles.  The 
ulcer  bleeds  easily,  is  generally  covered  with  a  single  large  scab ;  no 
plugs  can  be  expressed  from  it.  Glandular  enlargement  is  frequently 
.absent :  when  it  exists,  it  is  soft  and  involves  but  few  lymph  nodes. 

An  ulcerated  cavernoma  (cavernous  angioma)  may  look  some- 
what like  cancer,  but  the  young  age  of  the  subject  and  the  coexistence 
of  other  anomalies  of  the  blood-vessels  is  conclusive. 

The  induration  of  fissures  of  the  lips  resulting  from  chronic 
«czema  heals  quickly  under  appropriate  treatment. 


Much  depends  on  an  early  diagnosis,  because  a  small  tumor  may  be 
•easily  removed  by  a  cuneiform  excision,  while  large  growths  neces- 
sitates difficult  plastic  operations;  the  results  are  much  less  certain, 
and  the  disfigurement  is  much  more  marked.  This  removal  must 
always  be  preceded  by  a  thorough  cleaning  of  the  submental 
^nd  submaxillary  glands.    In  extensive  tumors,  from  half  an  inch 

8 


Bockenheiraer,  Atlas. 


Fig.  5.   Carcinoma  labii  inferioris  —  Tuberculosis  cutis. 


Rebman  Companj',  New-York. 


to  an  inch  of  lienltliy  tissue  sliould  he  removed  heyond  the  margin 
of  tlie  growtli,  and  tlie  n('i,u:hl)orin.u-  i^irts  suspected  of  disease,  such 
as  hones  and  huccal  mucous  meml)rane,  sliould  also  he  excised. 
In  the  case  represented  in  Fig.  3,  the  extensive  defect  was  repaired 
by  douhle  clieilo])lasty  aiiil  a  cure  was  ohtained. 


Fig.  5  rcprofiils  a  large  cancerous  ulcer,  niiij:iiiatin,i,'  t  rom 
tuberculosis  of  the  skin,  iinolvin.e;  half  the  lower  lip.  Such  an 
association  is  not  very  rare;  and  most  of  the  destructive  forms  of 
lupus  described  under  the  name  of  lupus  vorox  seem  to  depend  on  it. 
The  hard,  raised  edjjes  of  the  ulcer  divested  of  mucous  membrane 
are  characteristic.  The  floor  of  the  ulcer  is  irregular  and  ragged  and 
beset  Avith  yellowish  epithelial  plugs.  Cancerous  ulcers  developing 
on  a  previous  tulierculosis  of  the  skin  have  a  great  tendency  to  bleed. 
In  contrast  to  hypertrophic  lupus,  which  gives  rise  to  soft,  fungoid, 
slow-growing  tumors,  the  hardness  and  rapid  growth  of  Inpus- 
carcinoma  is  characteristic.  Excision  of  the  carcinoma,  removal  of 
the  glands,  and  rejiair  of  the  defect  by  Dicffciiharli's  cheiloplasty  led 
to  a  cure. 

Fig.  5  also  shows  a  charactoiistii'  jucture  of  different  forms  of 
cutaneous  tuberculosis  (lupus)  of  the  face.  Lupus  appears  most 
frequently  in  this  situation,  usually  begins  on  the  nasal  mucosa,, 
and  extends  over  the  face  in  the  shape  of  a  butterfly.  The  sharp, 
irregular  outline  on  the  forehead,  neck  and  behind  the  ears  is  char- 
acteristic. The  disease  begins  with  small  reddish-brown,  opple-jcUi/ 
like  nodules  situated  in  the  cutis  and  causing  exfoliation  of  the 
epidermis  (lupus  exfoliativa) ;  these  become  confluent  and  form  flat, 
reddish-gray,  easily  bleeding  ulcers  (lupus  exulcerans),  which  after 
healing  leave  radiating  cicatrices,  often  after  considerable  destruc- 
tion of  tissue.  (Fig.  5,  ear).  After  a  time  papillomatous  jirolifera- 
tions  of  soft  and  spongy  consistency  may  arise,  especially  about  the 
ear  (lupus  hypertrophieus).  These  three  forms  are  often  present  in 
the  same  patient. 

The  characteristic  lesion  of  lupus  i>  the  liiir/  of  sniall  apple-jcUf/ 
tubercles  at  the  i)eriphery,  while  the  center  has  already  healed.  If 
tho.se  elements  are  found,  the  diagnosis  is  certain,  unless  we  are  deal- 
ing with  some  mixed  lesion. 

Tieiitmail 

The  treatment  of  siikiU,  wcll-circumscrilied  lupic  lesions  may  be 
surgical  excision  followed  by  simple  suture  or  plastic  repair.   8crap- 

9 


ing,  scarifications,  cauterization  (thermocautery,  hot  air)  and  appli- 
cations of  strong  caustics  have  been  less  used  since  phototherapy 
(Finsen)  and  radiotherapy  have  given  brilliant  results.  These  are 
now  the  real  methods  of  treatment.  Radiotherapy  is  more  within  the 
reach  of  all  practitioners  than  is  phototherapy.  Freezing  with  a 
stick  of  carbonic  acid  snow  has  sometimes' been  employed  with  good 
success  {Pusey)  on  small  nodules  or  patches. 

The  general  dietetic  and  hygienic  antituberculous  treatment  is  a 
great  help;  and  injections  of  tuberculin  (TE)  in  small  doses,  to  avoid 
general  reaction,  may  prove  useful  in  refractory  cases. 


Figs.  6  to  9,  inclusive,  represent  epithelial  newgrowths  of  the 
tongue.    To  be  compared  with  Figs.  36,  117,  118,    119). 

Fig.  6  shows  a  flat  papilloma  which  was  removed  with  the  sharp 
spoon.  (About  the  nature  of  papilloma,  see  page  61.) 

Fig.  7  shows  on  the  left  half  of  the  tongue  an  extensive  papil- 
loma, and  on  the  right  a  superficially  ulcerated  carcinoma. 

Fig.  8  shows  a  deep  carcinoma  developing  under  a  patch  of 
leucoplakia:  it  is  not  jet  ulcerated  and  is  characterized  by  its 
hardness  and  irregular  outline.    This  central  location  is  exceptional. 

Fig.  9  represents  the  most  common  form  of  cancer  of  the 
tongue:  a  carcinomatous  ulcer  of  the  side  of  the  tongue  with  ex- 
tensive destruction,  leucoplakia  and  glandular  metastases. 

Cancer  of  the  tongTie  is  seen  almost  exclusively  in  men  after  the 
fortieth  year.  Alcohol  and  particularly  tobacco  favor  its  develop- 
ment. The  lesion  shown  in  Figs.  8  and  9  and  called  leucoplakia 
plays  an  interesting  part  in  the  production  of  ling-ual  cancer. 

Leucoplakia  is  a  hyperkeratosis  of  mucous  membranes,  particu- 
larly frequent  on  the  tong-ue  and  on  the  buccal  mucosa,  but  which  has 
also  been  observed  in  other  mucosfe,  e.g.  bladder  and  glans  penis 
(see  page  20).  It  forms  hard,  white,  opaline  patches  consisting  of 
horny  epithelium  and  raised  above  the  surface  of  the  adjacent 
mucous  membrane.  The  nature  of  leucoplakia  is  uncertain.  For- 
merly, it  was  considered  as  a  special  disease  in  itself  (buccal 
psoriasis) :  more  recently,  chiefly  under  the  influence  of  Fournier 

10 


Bockenheinier,  Atlas. 


Tab.  IV. 


Fig.  6.    Papilloma  linguae. 


Fig.  7.    Carcinoma  et  Papilloma  linguae. 


Fig.  8.    Carcinoma  linguae  incipiens.  Fig.  9.    Carcinoma  linguae  exulceratum.  —  Leukoplakia. 


Rebman  Company,  New- York. 


aud  his  pupils,  it  has  liecii  coiisiikTi'il  as  a  pnrasyiihiliti<;  keratosis — 
that  is,  an  affection  of  sypliilitic  orit/iu.  Iml,  not  (if  syphilitic  nature — 
devfloiiinn"  inulor  tlic  cornhiiHMl  iiitluciirc  df  syphilis  and  tol)acco. 
Tlii.v  view  is  iiiiw  liclil  li\  liic  iiiajmily  (if  sypliilologers.  A  third 
opinion  contends  that  IIh'ic  aic  Iwi.  kinds  dl'  Iciicoijlastic  lesions: 
first,  genuine  leiicophihin.  liypi'ikcratosi.v  of  unkiiovvn  origin,  hut 
having  nothing  to  do  with  syi)liilis;  second,  pseudo-lciicoplakia,  much 
more  frequent,  which  is  the  so-called  i)arasyphilitic  "leucoi)]alva" 
of  syphilologers.  Tiiis  tliird  ojiinion  seems  tlie  most  rational,  but, 
practically,  tlie  ]ioint  is  not  of  nnich  iini)ortance,  l)ecause,  he  it  pseudo- 
leucoplakia  or  genuine  leucoplakia,  all  these  patches  of  hyperkera- 
tosis have  an  unfortunate  tendency  to  undergo  malignant  epithelial 
degeneration.  In  fact,  cancer  is  the  natural  outcome  of  leucoplakia 
of  long  standing;  and  lingual  leucoplakia  is  found  in  the  antecedents 
of  one-half  of  the  cases  of  lingual  cari-iiKniia. 

The  surface  of  the  patch,  at  first  smooth  and  painless,  after  a 
time  becomes  fissured,  especially  after  excessive  smoking,  and  the 
lesion  becomes  deeper  and  sometimes  exceedingly  painful. 

The  treatment  of  leucoplakia  consists  in  the  avoidance  of  tobacco, 
alcohol  aud  spicy  food,  and  in  the  removal  of  patches,  either  with 
the  knife  or  with  the  thermo  or  galvano-cautery.  This  is  possible 
only  when  the  patches  ai-e  not  too  extensive.  Simple  cauterizations 
which  do  not  destroy  the  leucoplakia  patch  are  worse  than  useless, 
because  they  merely  irritate  and  tend  to  promote  malignant  degenera- 
tion, without  being  able  to  cure. 

Besides  leucoplakia,  jagged  carious  molar  teeth  also  act  as  ex- 
citing causes  of  cancer  of  the  tongue,  which  explains  the  almost 
exclusive  occurrence  of  cancer  in  the  posterior  part  of  the  side  of 
the  tongue.  Lingual  carcinoma  appears  in  two  forms,  according  as 
it  arises  from  the  superficial  miicnus  membrane  or  from  the  fjlandular 
epifkeUu)n. 

The  first  form  rosemlilcs  a  flat  cutaneous  carcinoma  and  soon 
gives  rise  to  a  small  ulcer  with  hard,  raised  edges  (Fig.  7,  right  half), 
the  fissured  surface  of  which  has  a  yellowish  or  dirty-brown  appear- 
ance. Although  the  carcinoma  is  only  superficial,  the  .submaxillary 
glands  are  soon  affected,  owing  to  the  alnindant  l>nii)hatii's  of  the 
tongue. 

Deep  carcinoma  begins  as  iiard  nodules  over  which  the  mucous 
memlirane  remains  intact  for  a  long  time.  After  the  breaking  down 
of  the  nodules  and  destruction  of  the  mucous  membrane,  an  extensive 
crateriform  ulcer  is  formed  with  hard,  irregular  edges  aud  deep^ 

11 


fissures  in  the  center.  This  often  reaches  as  far  back  as  the  epiglottis. 
Numerous  epithelial  plugs  can  be  expressed  from  the  floor  of  the 
ulcer,  and  often  from  the  papillomatous  proliferations.  The  patients 
suffer  great  pain  from  the  irritation  of  free  nerve  endings  in  the 
floor  of  the  ichorous  ulcer,  and,  in  untreated  cases,  usually  succumb 
within  a  year  from  glandular  metastases  extending  along  the  carotid 
to  the  supra-clavicular  region  (as  was  the  case  in  the  patient  repre- 
sented in  Fig.  9).  Early  diagnosis  is,  therefore,  of  the  greatest 
possible  importance. 

Diagnosis 

The  superficial  carcinoma  (Fig.  7)  is  recognized  by  the  character- 
istic features  of  flat  cutaneous  carcinoma  and  differs  from  syphilitic 
chancre  (see  Fig.  120)  by  its  sharp,  hard  edges,  the  irregular  floor 
of  the  ulcer  with  epithelial  plugs,  the  absence  of  spirochetse  pallidss 
in  the  scrapings  examined  under  the  dark-ground  illuminator.  As 
long  as  a  flat  carcinoma  of  the  tong-ue  is  covered  with  mucous  mem- 
brane it  may  in  its  earliest  stages  be  mistaken  for  papilloma 
(Fig.  6),  especially  in  the  rare  cases  where  it  lies  more  in  the  center 
of  the  dorsal  surface  of  the  tongue.  Papillomata,  however,  generally 
appear  as  multiple,  soft  elevations  the  size  of  a  pin's  head,  so  that 
the  surface  of  the  tongue  may  appear  dotted  with  small  points,  or 
may  assume  a  lobulated  form;  or  there  may  be  fungiform  sessile 
tumors,  like  stalactites,  which  often  form  high  projections  and  have 
a  warty  appearance  (Fig.  7).  A  flat  carcinoma  and  a  papilloma  of 
this  kind  may  occur  independently  without  microscopic  transition  into 
each  other.  Small  papillomata  cause  the  patient  hardly  any  incon- 
venience and  can  be  removed  with  the  sharp  spoon  or  Paquelin's 
cautery.    Larger  papillomata  should  be  excised  (Fig.  7,  left  half). 

A  small  carcinomatous  ulcer  of  the  edge  of  the  tongue  is  liable  to 
be  mistaken  for  ulcerations  caused  by  the  irritation  of  broken 
teeth  (dental  ulcers),  especially  when  it  is  situated  opposite  a  sharp 
tooth;  however,  the  cancerous  ulcer  continues  to  grow  after  removal 
of  the  offending  tooth. 

Larger  ulcerations  which  result  from  the  breaking  down  of  deep 
carcinoma  may  be  confounded  with  a  gumma  on  superficial  examina- 
tion. The  latter,  however,  is  almost  always  situated  in  the  center 
of  the  tongue  or  in  its  anterior  part,  and  has  the  characteristic  dirty- 
yellow,  gummatous  core,  which  can  be  removed  without  bleeding 
(Fig.  119),  in  distinction  to  the  easily  bleeding  reddish-brown  pro- 
liferations of  carcinoma.     Moreover,  the  pain  radiating  to  the  ear 

12 


which  is  constnntly  present  in  larp;e  oarfinomnta  is  alisont  in  jjurnjna; 
also  tlie  glandular  metastases  and  the  leucoplaUia. 

Tn  cases  of  small,  non-ulcerated  tumors,  tlie  diagnosis  is  more 
diriicuH  ami  iiiay  again  liesitate  l)et\veen  a  cancer  and  a  gumma. 
Here  the  Was^ermaiin  reaction  is  of  little  helji  when  negative;  it 
simply  increases  the  suspicion  of  cancer  witliout  proving  anything; 
a  test  course  of  aiitisy|iliilitic  t rcalmi'iit  wastes  tdn  inin-li  precious 
time  so  that  //'  tlie  iHitinntsis  Is  rmlln  Impossible  h//  c/iininl  means, 
excision  of  a  jiiccc  ami  immediate  hislnhir/ical  examination  i)y  a  corn- 
competent  j)atluilogist  is  justilied,  Init  only  if  radical  removal  is  to 
follow  without  delay,  should  malignancy  be  proved  (as  unfortunately 
happens  practically  in  all  "suspicious"  cases);  else  such  excision 
has  all  the  inconveniences  of  partial  ablation  in  cancer. 

The  diagnosis  is  also  difficult  when,  as  in  Fig.  8,  a  hard,  carcino- 
matous nodule  develops  under  a  patch  of  leucoi)lakia.  The  irregular, 
deep,  hard  infiltration  and  the  rapid  increase  point  to  a  commencing 
new  growth,  which  should  always  be  removed  before  it  breaks 
through,  especiall\  as  when  there  is  lencoiilakia  over  the  nodule, 
malignancy  must  always  be  suspected. 

Semi-chronic  abscesses  of  the  tongue,  V'^u]]  result  iVdiii  injury 
by  foreign  bodies  (steel  pens,  etc.),  and  form  hard  lumps  in  the  sub- 
stance of  the  tongue,  are  characterized  by  the  early  painfulness  on 
IDressure.  Actinomycosis  causes  a  more  diffuse,  woody  infiltration 
of  the  whole  tongue  and  very  soon  interferes  with  its  motion. 

Treatment 

Tlio  treatment  of  lingual  carcinoma  is  always  total  removal 
of  the  tongue  and  its  lymph  glands.  Partial  excisions  are  always 
iusulticient,  even  in  the  rare  cases  of  seemingly  well  localized  lesions 
of  the  anterior  half,  and  excision  of  the  tongue  without  the  lymph 
glands  should  never  be  performed. 

The  best  surgical  technique  for  the  removal  of  the  tongue  is  that 
in  which,  as  a  preliminary  step,  all  the  lymph  glands  of  the  sub' 
maxillary  and  submental  regions  are  cleaned  out  and  both  lin- 
gual arteries  are  ligated.  This  step  is  wholly  aseptic,  'flic  extirpa- 
tion of  the  tongue  is  effected  a  few  days  later.  It  is  almost  bloodless, 
owing  to  the  previous  ligation  of  the  lingual  arteries,  and,  the  tongue 
being  already  markedly  shrunken,  its  removal  is  nmch  easier.  There 
is  less  chance  of  being  compelled  to  tlivide  the  lower  jaw,  either  in  the 
midline  or  laterally;  however,  such  a  division  remains  necessary  if 
the  carcinoma  extends  far  back. 

13 


Even  after  extirpation  of  extensive  portions  of  the  tongue  the 
patients,  after  a  few  months,  can  make  tliemselves  well  understood. 
Permanent  cures  are,  however,  unfortunately  rare,  even  after  radical 
operations  performed  before  any  hardened  lymph  nodes  can  be  felt 
in  the  submental  region,  so  that  some  surgeons  content  themselves 
with  the  local  palliative  treatment  of  carcinoma  by  applications 
intended  to  relieve  pain.  X-ray,  radium,  and  high  frequency  treat- 
ment does  not  yield  results  in  lingual  carcinoma.  Early  and  extensive 
removal  is  the  only  hope,  and  it  is  none  too  promising. 

The  treatment  of  cancer  of  the  buccal  cavity,  which  often  develops 
from  leucoplakia,  with  the  same  symptoms  and  objective  aspect  as 
lingual  carcinoma,  is  carried  out  on  the  same  principles.  The  closure 
of  extensive  defects  of  the  cheek  is  no  easy  task  in  most  cases.  A 
mucous  lining  must  be  provided  for  the  buccal  side.  Cicatricial 
retraction  often  hinders  almost  completely  motion  of  the  lower  jaw; 
section  of  the  ramus  of  this  bone  at  the  time  of  operation  prevents 
this  cicatricial  ankylosis  (Bodine). 


Figs.  10  to  16,  inclusive,  show  a  number  of  types  of  carcinoma 
of  the  breast. 

(Other  lesions  of  the  breast,  see  Figs,  29.  30,  37,  85  and  86.) 

Of  the  carcinomata  of  glandular  organs  those  of  the  female  mam- 
mary gland  are  among  the  most  common  (they  take  the  third  place). 
A  division  into  soft,  many-celled,  rapidly  growing  tumors  of  which 
the  medullary  cancers  represent  the  most  malignant,  and  slow- 
growing  scirrhous  forms  with  few  cells,  is  of  clinical  importance. 

The  exciting  causes  include  inflammatory  irritation,  puerperal 
interstitial  mastitis,  eczema  of  the  nipple,  antecedent  benign  tumors 
(fibro-adenoma,  cysts),  injuries,  mechanical  irritation,  frequent  par- 
turition with  prolonged  suckling  of  infants.  Cancer  of  the  breast 
is  attributed  by  the  laity  to  injuries  (blows),  but  these  are  often  too 
recent  to  be  accepted  as  an  etiological  factor,  considering  the  slow 
growth  of  the  carcinoma. 

The  activity  of  the  gland  in  lactation  is  a  predisposing  cause  of 
cancer.  Only  10  per  cent,  of  the  cases  of  breast  carcinoma  are  seen 
in  sterile  women.  The  weakening  action  of  pregnancy  and  lactation 
is  well  shown  in  the  type  known  as  carcinoma  mastitoides  (Schur- 
man)  or  mastitis  carcinomatosa  {V olkmann)  (see  Fig.  16),  which 
is  the  most  malignant  form  of  all. 

Women  are  most  often  affected  at  the  menojoause   (fortieth  to 

14 


Bockcnheimer,  Atlas. 


Tab.  V. 


Fig.  10.    Carcinoma  mammae  —  Lympliomata  carcinomatosa. 


Rebman  Company,  New-York. 


fifty-fifth  years),  and  come  to  tlie  surgeon  with  nodules  in  tlie  l)reast 
wliich  liavo  l)een  hitherto  ])ainh>ss  and  are  only  ar-fidentally  ohserved. 
Tliese  nodules  very  soon  I'diin  .-i  iii;iliu!iaii(  u'rowtli  ol'  lianl  I'Diisisteney 
and  irregular  surface. 

The  most  iiii|Hirlaii1  siiiii  ol'  a  nialiL;iiaiit  jiew  growth  is  the 
absence  of  any  demarcation  or  encapsulation.  The  tumor  cannot, 
like  all  benign  luiiiors,  lie  separated  rroin  the  mannnary  tissue  and 
moved  freely,  hut  is  fixed  iinmovaMy  in  the  glandular  tissue,  with 
ill-defined  boundaries,  and  is  nncluireil  in  the  meshes  of  the  mammary 
tissue  by  numerous  offshoots.  The  nodules,  wliirh  at  first  ajtpear 
liarmless,  thus  soon  show  their  malignity. 

Progressively  the  tumor  sends  its  destructive  extensions  in  all 
directions  into  the  neighboring  tissues,  without  limit  or  restraint, 
and  reaching  the  surface  adbei'es  to  the  skin  and  causes  dimpling 
of  the  skin,  retraction  and  fixation  of  tfie  nipple.  Finally,  it  gives 
rise  to  a  liard  inflammatory  infiltration  of  the  whole  of  the  overlying 
skin.  At  the  same  time  the  tumor  extends  deeply  and  soon  intiltrates 
the  lymphatics  beneath  the  pectoralis  major  muscle  and  also  the 
regional  lym])hatie  vessels  and  glands  of  the  axilla  (Fig.  10),  which 
are  usually  affected  about  a  year  after  the  formation  of  the  nodules 
in  the  breast,  and  take  the  form  of  hard,  solid,  painless  lumps,  which 
are  often  difiticult  to  feel  in  corpulent  women.  Extensive  glandular 
involvement  gives  rise  to  radiating  pain  and  edema  of  the  arm 
(supra-clavicular  glands).  Although  the  cancer  usually  arises  as  a 
single  nodule,  there  are  cases  in  which  several  nodules  develop  simul- 
taneously (Fig.  10)  and  extend  through  the  whole  breast  to  the 
axilla  (Fig.  10).  The  prognosis  is  unfavoiable  in  these  cases,  and  in 
disease  of  both  breasts  (Fig.  15). 

Cancer  is  very  frequently  situated  in  the  upiiei-  and  outer  quad- 
rant of  the  breast,  especially  on  the  left  side.  The  tumors  situated 
in  the  outer  half  of  the  mamma  towards  the  axilla,  wrongly  called 
paramannnary  earcinomata,  are  really  glandular  cancers,  for  they 
originate  in  the  offshoots  of  the  mamma,  which  extend  toward  the 
clavicle,  stei'num,  axilla  and  twelfth  rili  in  the  form  of  long,  thin  cords. 

Cancer  of  the  breast,  like  all  cancers  rich  in  cells  (acinous,  tubu- 
lar), grows  rapidly,  es]ieci;illy  during  pregnancy,  and  causes  destruc- 
tion of  the  skin.  A  cancernns  ulcer  results,  characterized  like  cutane- 
ous carcinoma  by  its  liai-d.  laised,  tixed  borders,  crateriform  base  and 
sanious  discbai-ge.  A  liaiil  inlilti-ation  develops  around  the  tumor, 
which  is  usually  liiinly  iidlinent  t<i  llie  thorax.  Small  nodular  thick- 
enings of  tlie  adjacent   unlimken  skin  sometimes  constitute  the  first 

l.i 


sign  of  commencing  general  cutaneous  dissemination  (Fig.  11).  In 
this  way  the  whole  mamma  may  be  transformed  into  a  large  ulcer 
(Fig.  15). 

In  other  eases  the  tumor  is  gradually  developed  and  involves  the 
whole  breast  without  breaking  through  externally.  The  skin,  how- 
ever, may  be  infiltrated  and  the  redness  may  be  mistaken  for  inflam- 
matory infiltration  (Figs.  14  and  16).  These  leathery  infiltrating 
forms  of  breast  cancer  finally  develop  the  whole  mammary  region 
like  a  cuirass  (Fig.  15). 

In  the  infiltrated  skin  there  often  appear  small,  pin-point,  dissem- 
inations of  the  carcinoma  (Fig.  15,  right  side),  which  by  confluence 
give  rise  to  a  nodular  infiltration  of  the  whole  thorax  (Fig.  14). 

In  scirrhous  cancers,  which  are  poor  in  cells,  the  mammary  gland 
is  often  diminished  in  size  by  shrinking  and  the  skin  becomes  puckered 
over  the  tumor  by  cicatricial  contraction  (Fig.  10). 

Differential  diagnosis 

An  advanced  ulcerated  cancer  of  the  breast,  or  one  with  hard 
and  raised  infiltration,  is  easy  to  recognize,  but  those  are  not  the 
interesting  cases  to  diagnose  accurately,  because  they  have  already 
reached  a  stage  where  chances  of  a  permanent  cure  after  operation 
are  rather  slight. 

Small,  young  tumors,  on  the  other  hand,  are  often  difficult  to 
diagnose  properly.  Benign  tumors  (fibro-adenoma,  cysts  and  mixed 
tumors),  chronic  interstitial  mastitis,  abscesses  in  which  there 
frequently  is  deceptive  induration,  tuberculosis,  galactocele  are  as 
many  stumbling  blocks. 

The  age  of  the  patient  has  nothing  characteristic;  particularly  in 
tumors  of  the  breast,  age  is  not  a  factor  that  allows  to  rule  out 
malignancy. 

The  continuous  growth  of  the  nodules,  the  appearance  of  glandular 
enlargement,  still  more  the  cachexia  are  things  for  which  we  should 
not  have  to  wait  in  order  to  be  able  to  make  a  diagnosis. 

As  regards  "benign"  tumors,  the  only  safe  rule  is  always  to  view 
them  with  suspicion.  Benign  tumors  in  the  breast  are  rare  as  com- 
pared with  malignant ;  the  proportion  being  less  than  1  to  10.  Many 
tumors,  long  classified  among  the  benign,  have  now  passed  to  the 
malignant  group :  e.g.,  cystic  disease  of  the  breast,  now  called  pap- 
illary cystadenoma,  and  unquestionably  malignant  in  many  instances. 
Finally,  a  really  benign  tumor  is  liable  to  undergo  malignant  degen- 
eration after  years  of  benign  evolution.    As  a  rule,  every  breast  tumor 

16 


I'liiL'kculu'iiiier,  Atlas. 


Tab.  VI. 


L) 


Kebnian  Coiiip.my,  Ncw-\'ork. 


iilidiil  wliicli  I  lie  siii'.ycon  li;is  even  a  va,u-iio  siis|)icioii  oi'  inaliiniaiK-y 
I  urns  dill  to  he  maligna  111.  I  li'in'c,  we  must  deem  malignant  every 
breast  tumor  the  character  of  which  does  not  establish  beyond 
doubt  its  non-malignancy,  and  ad  aironlinjrly. 

'J'lie  great  aiiatoiiiiral  rcaluic  of  iioii-inalignant  tumors  is  encap- 
sulation. A  perfectly  well  liinilcil  growth,  movable  in  the  gland 
tissue,  non-adhcroTit  In  any  sliinliiro,  is  likely  to  he  l)eni.gn.  Any 
tiiinor  tliat  is  IVIt  to  send  offsliools  in  glandular  tissue  is  cancer. 
The  diagnosis  of  ehrouir  interstitial  mastitis  is  particularly  dillicuit; 
perha])s  only  because  there  exist  between  this  coiidilion  and  cancer 
intimate  relations  not  as  yet  elucidated.  Microscopical  examination 
of  an  excised  piece  must  be  performed  in  all  doubtful  cases;  and  if 
even  the  microscope  (as  will  ha])pcn  sometimes)  is  unable  to  give  a 
definite  answer,  the  breast  must  bo  removed.  Eather  remove  a  chron- 
ically inflamcil  ln-rasl  than  give  cancer  too  long  a  chance. 

Sarcoma  occuis  at  an  eai-lier  age  and  has  a  fairly  typical  appear- 
ance (Figs.  29  and  30) ;  but  a  mistake  in  diagnosis  is  not  very  impor- 
tant, since  liotli  conditions,  sarconui  and  cancer,  call  for  the  same 
treatment. 

The  same  may  be  said  of  infiltrating  forms  of  tuberculosis  of 
the  breast,  which  are  not  exceedingly  rare. 

Trea  tmeni 

The  treatment  of  bi-east  carcinoma  is  radical  excision  of  the 
whole  breast  and  itsprocesses  as  early  as  jxissihle  with  removal 
of  the  pectoralis  major  and  minor  muscles,  and  complete  cleaning 
out  of  the  axillary  glands  {Ilahted's  or  WiUy  Mciicr\s  technique). 
As  in  all  operations  for  cancer,  squeezing  of  the  breast  during  re- 
moval must  be  carefully  avoided,  so  as  not  to  spread  cancerous  seed 
over  the  operative  wound.  In  fact,  recurrences  are  much  more  com- 
mon in  the  scar  than  anywhere  else.  If  small,  they  can  he  excised 
again. 

Operation  is  coiitraindieated  in  all  cases  with  extensive  dissem- 
ination in  the  skin,  diffuse  infiltrating  cancer,  "(■a)iccr  en  cuirasse" 
(Figs.  15  and  16),  also  when  the  supraclavicular  glands  are  involved, 
in  slow  growing  scirrhus  of  \'ei'>'  old  i)eople,  and  in  cases  where 
organic  metastases  ai-e  pi-esent. 

X-ray  treatment  is  good  in  the  post-operative  period,  but  cannot 
cure  cancer  without  operation.  A  carcinomatous  nodule  ma.v  disin- 
tegrate and  disapjiear  under  its  influence,  and  sui-face  epidennization 
occur,  but  the  canccr(nis  pi-ocess  continues  in  the  deeper  tissues.    The 

17 


same  is  true  of  radium  and  fulguration.  Nevertheless,  X-rays,  fulgu- 
ration,  scrapings,  cauterizations  are  useful  in  the  palliative  treat- 
ment of  inoperable  cancer. 

No  cancer  serum  has  as  yet  gone  beyond  the  experimental  stage 
or  given  durable  results. 

Fig.  10  shows  an  acinous  carcinoma  forming  several  nodules 
in  the  breast,  already  infiltrating  the  skin.  The  axillary  glands  are 
felt  as  hard,  fixed,  indolent  lumps,  and  a  chain  of  nodules  can  be 
easily  traced  from  the  mammary  gland  to  the  axilla.  The  nipple  is 
retracted  and  fixed,  and  the  whole  breast  is  diminished  in  size.  Opera- 
tion was  performed  in  the  i;sual  way.  The  patient  was  already 
emaciated. 

Fig.  11.  A  single  cancerous  nodule  in  a  male  breast.  The  skin 
has  broken  down  and  shows  a  cancerous  ulcer  with  hard,  raised, 
jagged  edges,  which  has  destroyed  the  nipple.  The  floor  of  the 
ulcer  is  irreg-ular  and  the  whole  tumor  is  fixed  to  the  pectoral  muscle. 
At  the  edge  of  the  ulcer  the  skin  is  radially  contracted  and  shows  iso- 
lated cancerous  nodules.  The  axillary  glands  are  hard,  visible  and 
hardly  movable.  In  spite  of  the  small  size  of  the  tumor,  there  was 
already  cachexia.  After  removal  of  the  mamma  with  the  pectoralis 
major  and  the  axillary  glands  the  wound,  which  could  not  be  com- 
pletely clofeed  by  suture,  as  is  frequently  the  case  in  women,  but  almost 
the  rule  in  men,  was  repaired  by  Thiersch  {see  Fig.  55)  grafts. 

Cancer  of  the  male  breast  (about  1  per  cent,  of  all  mammary 
carcinomata  according  to  Schuchardt)  generally  arises  as  a  small, 
hard  nodule  (scirrhus)  in  the  neighborhood  of  the  nipple  and  gives 
rise  to  a  typical  cancerous  ulcer.  The  tumor  occurs  between  the 
fortieth  and  seventieth  years. 

Fig.  12  shows  a  very  rare  case  of  carcinoma  arising  from  the 
nipple  (squamous-celled  epithelioma).  This  is  more  common  in 
men  than  in  women.  It  begins  as  a  hard  infiltration  of  the  nipple, 
in  the  same  way  as  does  incipient  carcinoma  of  the  navel.  The  nipple 
is  much  retracted  and  the  whole  areola  is  transformed  into  a  rigid 
wall.  A  cancerous  ulcer  soon  develops  which  destroys  the  nipple  and 
areola.  At  first  there  is  no  connection  between  this  cutaneous  cancer 
and  the  mammary  gland. 

The  treatment  consists  i)!  early  extirpation  of  the  mammilla  with 

18 


I^nrkcnlipiincr,  Atlas. 


Tab.  VII. 


I"itr.  12.    Carcinoma  maiiiiiiillac. 


Ri'lnii.iii  Comp.iiiy,  Ncw-\'ork. 


Bockcnheiiiicr,  Atlas. 


Tab.  VIII. 


Fig.  13.     Carcinoma  mammae  —  Pacret  Disease  —  Eczema  cliroiiiciim  mammillae. 


Rcbman  Company,  iNcw-York. 


ockenlieinu'i,  Atlas. 


I'iy.  14.    C-'aiiiiKima   niaiiimae     -  Disscminalioiics. 


'bni.tii  ('(iinp.iuy,  Nc\v-\'ork. 


iockciihcimcr,  Alias. 


Tab.  X. 


Kebinan  Company,  New-York. 


the  subjacent  iii.iinin.ny  tissue,  by  means  of  an  oval  incision  with 
subsequent  suture.  KecuiTence  is  rare  after  early  treatment.  In 
doubtful  cases  with  induration  of  llic  maininilla  excision  should 
always  be  pcrforinod. 

Fig.  13.     Paget' s  disease,  nr  chronic  eczema  of  the  nipple, 

wliicli  is  rofrac'lory  lo  all  trfalinciit.  Tlii'  (■(•zciiia  lii'i;iiis  on  tliu 
nipple  and  .uTadually  extends  to  the  areola  and  surrounding  skin. 
Retraction  of  the  nipple  and  dra.irs'ing  i)ains  are  caused  by  the  pres- 
ence, under  the  nipple,  of  carcinouia  (cyiiuder-epithelioma),  which  at 
first  has  no  connection  with  the  nipple,  but  later  on  may  become 
attached  to  it.  The  mammarj'^  gland  in  this  ease  shows  hard  infil- 
tration around  a  nodule.  In  the  normal  parts  of  the  skin  there  are 
small  dimples.  Obstinate  eczema  of  the  nipple  accompanied  by  a 
tumor  in  the  breast,  with  infiltration  of  the  axillary  glands  and  early 
cachexia,  make  the  diagnosis  clear  and  indicate  removal  of  the  whole 
mammary  gland  with  the  axillary  glands.  In  cases  of  chronic  eczema 
of  the  nipple  resisting  all  treatment,  excision  of  the  mammilla  is 
advisable.  Out  of  884  cases  of  mammary  carcinoma  in  v.  Bergmann's 
clinic  there  were  only  seven  typical  cases  of  Paget's  disease.  Two 
of  the  author's  cases  showed  cancer  of  the  mammary  gland  without 
connection  with  the  eczematous  ni])]ile. 

Fig.  14.  This  is  a  case  of  tubular  carcinoma  with  cutaneous 
dissemination  which  has  extended  in  all  directions  and  spread  over 
the  thorax.  The  development  of  nodules  in  the  skin  occurs  early. 
These  appear  at  first  as  punctiform,  bluish,  glistening  elevations, 
which  increase  in  number  and  size  and  coalesce,  forming  a  kind  of 
cuirass  inclosing  the  thorax  in  a  rigid  mass  {"Cancer  en  cuirasse"). 
These  cases  are  inoperalile. 

Fig.  15.     This  is  a  case  of  inoperable  cancer   "en  cuirasse," 

in  whi<'h  both  mamma>  are  affected  with  carcinoma.  On  the  right  side 
there  has  been  a  recurrence  of  the  growth  in  the  scar  soon  after  opera- 
tion, where  a  soft,  fungating,  easily  bleeding  ulcer  is  seen.  In  the 
surrounding  skin  there  are  several  isolated  nodules.  The  left  mam- 
mary gland  is  involved  in  a  hard,  immovable,  carcinomatous  infiltra- 
tidii.  Tlie  transmigration  (if  a  caicinoma  from  one  side  to  the  other 
is  possibly  cx]iliiIiH'd  liy  the  ]>ersistence  of  congenital  lyiiii)liatics. 


19 


Fig.  16.  At  first  sight  this  appears  to  be  a  pyogenic  inflamma- 
tion. (Compare  with  Figs.  85  and  86.)  However,  the  bluish  color, 
the  retraction  of  the  nipple,  the  hard,  immovable  breast  forming  a 
large  tumor,  and  the  extensive  metastases  in  the  axillary  and  supra- 
clavicular glands  lead  to  a  diagnosis  of  carcinoma.  Volkmann  has 
named  this  not  very  rare  form  of  cancer  mastitis  carcinomatosa 
and  Schurman  carcinoma  mastitoides.  That  we  have  here  to  deal 
with  an  affection  of  the  lymphatics  (lymphangitis  carcinomatosa) 
is  shown  by  the  jDunctiform  red  spots  between  the  two  breasts,  the 
larger  punctiform  or  circular  spots  below  the  clavicle  and  the 
changes  in  the  region  of  the  neck.  The  latter  is  of  a  blue 
color  and  the  seat  of  a  hard  infiltration,  which  is  not  inflammatory, 
but  due  to  lolugging  of  the  lymphatics  with  cancer  cells,  and  consecu- 
tive edema.  This  form  of  cancer  is  hardly  seen  except  during  preg- 
nancy or  lactation,  when  there  seemingly  exists  a  special  vulnerability 
of  the  breast  cell.  Therefore  this  acute  form  of  carcinoma  is  seen 
more  frequently  than  the  other  forms  in  young  women ;  and  in  not  a 
few  instances,  it  is  bilateral. 

The  last  three  plates  (Figs.  14,  15  and  16)  show  the  terrible 
effects  of  advanced  cancer  of  the  breast,  so  that  the  necessity  for  the 
earliest  possible  diagnosis  and  radical  removal  by  operation  must 
once  more  be  set  forth  emphatically. 


Fig.  17  shows  a  rapidly  growing  tumor  developed,  in  a  man  aged 
37  years,  on  a  congenital  n«vus.  Degeneration  of  such  a  nsevns, 
of  an  old  sear,  ulcer,  wart,  sebaceous  cyst  (Fig.  18)  or  mole,  is  the 
origin  of  all  cancers  of  the  scalp,  which  are  very  rare.  Papilloma, 
sarcoma  and  melanoma  are  other  possible  evolutions. 

The  cutaneous  covering  of  the  nsevus  was  quickly  destroyed  and 
the  tumor  was  formed  by  cauliflower  growths  separated  by  deep 
fissures.  The  ulcerated  surface  was  covered  with  sanious  secretion, 
so  that  the  naked-eye  appearance  was  not  sufficient  to  establish 
whether  the  case  was  one  of  sarcoma  or  carcinoma.  However,  the 
malignant  character  was  not  doubtful,  on  account  of  the  rapid 
growth,  the  cachexia  and  the  lymph-gland  metastases,  which  soon 
extended  along  the  large  vessels  of  the  neck  down  to  the  supra- 
clavicular fossa.  These  lymphatic  metastases  favo.r  the  diagTiosis  of 
carcinoma  as  against  that  of  sarcoma. 

This  case  was  inoperable.     A  less  advanced  tumor,  without  any 

20 


B  keiiliciiiRT,  Atlas. 


% 


Fig.  16.     Carcinoma  mammae.  —  Lymphangitis  carcinomatosa. 


:bnian  CoTuiiaiiy,  Ncw-Yoik. 


Bockenheimer,  Atlas. 


Tab.  XII. 


U 


< 


u 


palpable  lymph  glands,  would  iciiuiic  a  wido  excision  of  the  tmiior 
and  oi'  tlie  ikwus.  (  Koi-  tiie  treatment  of  iiM'vi,  xr  Figs.  67,  68, 
76  and  page  1U4).  As  soon  as  cliaiiiii's  uf  any  kind  apitear  in  a  na'vus, 
it  is  important  to  remove  it  forthwith.  It  is  best  to  excise  all  pig- 
mentary urcvi  because  they  are  too  often  the  startinir  ])nint  of  fatal 
melanotic  growths  (see  Figs.  23  and  28)- 


Fig.  18  si  lows  a  carcinoma  of  the  scalp  originating  in  a  seba- 
ceous cyst.  Ordinary,  non-dege7ierated,  sebaceous  eysts  are  scat- 
tered over  the  whole  scalp.  Beginning  as  small  nodules  inlaid  in  the 
skin,  these  eysts  slowly  grow  into  large  tumors  with  a  broad  base 
and  smooth  surface.  They  are  fixed  to  the  skin,  but  easily  movable 
over  the  subjacent  bone,  and  have  a  doughy  consistency  often  re- 
sembling fluctuation.  If  this  mobility  of  the  cyst  over  the  subjacent 
tissues  ceases  and  the  originally  soft  tumor  becomes  a  hard  nodule 
with  an  irregular,  rough  surface,  malignant  degeneration  is  to  be 
suspected;  apart  from  the  occurrence  of  calcification  in  its  walls,  in 
which,  moreover,  the  spherical,  smooth  surface  is  generally  preserved. 
This  suspicion  becomes  a  certainty  wlieu  the  skin  gives  way  and 
there  appears  a  rapidlj''  growing  nodular  tumor  characterized  by 
multiple  lobulation  and  secreting  a  fetid  discharge.  Such  a  carci- 
noma resembles  in  many  ways  an  ulcerated  sarcoma  (Fig.  33),  and 
often  causes  severe  pain  owing  to  inflammation  around  the  tumor. 
Cachexia  occurs  early,  and  the  patients  are  usually  of  advanced  age. 

The  digTiosis  of  carcinoma  depends  on  the  characteristics  men- 
tioned above  and  later  on  the  hard  multiple  glanclular  enlargement, 
which  affects  the  whole  nape  of  the  neck.  This  usually  occurs  late 
and  is  not  so  hard  in  sarcoma. 

Treatment 

This  consists  in  extirpation  of  the  carcinoma,  and  involves  re- 
moval of  part  of  the  external  table  of  the  skull  on  account  of  the 
tumor  being  fixed  to  it.  The  extensive  space  left  by  removal  of  the 
tumor  can  be  sutured  after  making  two  long  lateral  incisions  over 
both  ears  and  undermining  the  scalp.  The  spaces  left  by  the  lateral 
incisions  can  be  repaired  by  Thiersch  grafts.  The  glands  in  the  nape 
of  the  neck  must  also  be  removed. 

On  account  of  the  early  apjiearance  of  glandular  metastases  the 
excision  of  especially  indurated  sebaceous  cysts  is  indicated.  More- 
over, as  there  is  always  a  possibility  of  malignant  degeneration,  it 

21 


is  advisable  to  remove  every  sebaceous  cyst  by  dissecting  it  out,  so 
as  to  avoid  recurrence. 

Fig.  19  shows  the  ordinary  clinical  appearance  of  carcinoma 
of  the  penis. 

Carcinoma  of  the  penis  begins  on  the  glans  or  in  the  coronary 
sulcus  as  a  squamous-celled  epithelioma,  generally  between  the 
fiftieth  and  seventieth  year.  Predisposing  causes  are  all  chronic 
irritations  of  the  region ;  for  instance,  congenital  phimosis  with  pre- 
putial concretions,  leucoplakia  preputialis  (white,  glistening  patches 
similar  to  leucoplakia  of  the  tongue  and  cheek,  see  page  8),  warts, 
long-standing  tuberculous  and  syphilitic  ulcerations.  Old  fistulae, 
which  occur  especially  in  eunuchs  after  removal  of  the  scrotum, 
testicles  and  pendulous  part  of  the  penis,  near  the  symphysis  or 
perineum,  also  predispose  to  carcinoma.  "Chimney  sweep's  cancer" 
is  a  cutaneous  cancer  observed  on  the  scrotum  and  is  due  to  the  irri- 
tation of  soot  and  dirt. 

The  usual  form  of  penile  carcinoma  is  that  represented  in  the 
figTire,  a  warty  carcinoma  which  destroys  the  prepuce  a2id  soon  forms 
a  cauliflower  growth.  Between  the  separate  hard  nodules  destitute  of 
skin  appear  crateriform  excavations  which  are  characteristic.  Epithe- 
lial plugs  can  be  expressed  from  the  growth,  and  in  other  parts  the 
surface  is  cornified.  Thus,  continuous  growth  alternates  with  per- 
manent disintegration.  The  rapidly  developing  nodules  often  cause 
exhausting  hemorrhage,  while  the  breaking  down  of  the  carcinoma 
gives  rise  to  a  fetid  sanious  discharge.  The  borders  of  the  growth  are 
hard,  raised  and  prominent.  The  whole  penis  may  be  transformed 
into  a  large  tumor,  which  may  extend  to  the  scrotum,  testicles  and 
pelvis.  The  growth  may  destroy  the  urethra  and  cause  much  pain 
on  micturition. 

A  more  rare  form  of  carcinoma  arises  as  a  small  ulcer,  generally 
on  the  corona  glandis. .  It  is  hidden  by  the  resulting  phimosis,  but  its 
characteristic  hard  borders  can  be  felt  distinctly  and  there  is  a  sanious 
secretion.  The  inguinal  glands  are  affected  early  and  point  to  the 
diagTiosis  of  carcinoma.  The  growth  at  first  causes  the  patient  little" 
inconvenience,  but  quickly  leads  to  severe  cachexia,  so  that  the 
patients  often  present  themselves  with  extensive  metastases  of  the 
inguinal  and  retroperitoneal  glands,  and  are  in  an  inoperable  con- 
dition. A  saying  of  Kauffmann's,  "In  old  men  with  phimosis  and 
offensive  discharge  the  possibility  of  cancer  is  always  to  be  borne 
in  mind,"  merits  special  consideration. 

22 


Bockciilicimcr,  Atlas. 


Fig.  19.    Carcinoma  penis  —  Leukoplakia. 


Kcbinnn  Company,  Nc\v-\'ork 


plugs.    A  cauliflower  tumor  grows,  which  soon  becomes  fixed  to  the 
fascia  (Figs.  20  and  22). 

Warts,  old-standing  ulcers  of  the  leg  and  lupoid  changes  in  the 
skin  also  lead  to  carcinoma  of  the  extremities.  Eczema  of  the  skin 
occurring  in  chimney-sweeps  and  workers  in  paraffin  has  often  led  to 
multiple  carcinoma  of  the  extremities  and  scrotum. 


Fig.  20  shows  a  papillary  carcinoma  of  the  skin  of  the  leg 

arising  from  the  scar  of  a  burn.  The  smooth,  partly  white  and  partly 
brownish,  shiny  scars  of  the  burn  are  seen  over  the  whole  leg.  The 
carcinoma  has  extended  above  and  below  and  has  extended  around 
the  whole  circumference  of  the  leg.  The  soft,  cauliflower  prolifera- 
tions have  given  rise  to  severe  hemorrhages.  From  the  depth  of  the 
growth  oozes  a  sanious  discharge.  The  borders  of  the  tumor  are 
very  hard  and  raised,  and  are  immovable  over  the  fascia.  The 
inguinal  glands  were'  already  involved. 

Amputation  was  performed  through  the  thigh,  and  the  inguinal 
glands  were  removed.  Though  adenitis,  in  cancer  of  limbs,  may, 
-perhaps,'  not  be  a  formal  contraindication  of  operative  inference,  it 
considerably  increases  the  chances  of  a  recurrence.  Therefore,  here 
also,  as  in  all  cases  of  tumors,  an  early  diagnosis  is  essential.  As 
soon  as  a  chronic  ulcer  of  the  leg  begins  to  show  marked  induration 
of  the  borders  and  proliferation,  the  suspicion  of  carcinoma  is  justi- 
jied,  and  it  is  best  to  remove  the  whole  ulcer  as  soon  as  possible. 

For  X-ray  carcinoma,  see  Fig.  138  and  page  219. 


Fig.  21  shows  a  carcinoma  in  a  common  situation,  the  back  of 

ihe  hand,  arising  from  a  wart  and  forming  a  characteristic  carcino- 
matous ulcer.  As  the  growth  was  still  movable  over  the  fascia,  and 
there  were  no  glandular  enlargements,  it  was  excised  and  the  gap 
repaired  by  a  pedunculated  flap  from  the  forearm.  The  rapid  growth 
of  these  small  tumors  with  hard  borders  makes  early  diagnosis  and 
removal  necessary,  so  as  to  avoid  recurrence.  Compare  with  rodent 
■ulcer  of  Fig.  1. 


Fig.  22  shows  a  very  extensive  carcinoma  arising  from  the  scar 
of  an  injury  two  years  before.  In  this  case  the  irregular,  wall-like, 

24 


Tab.  XV. 


U 


u 


Rebm.-iii  Company,  New- York. 


Bockenheimer,  Atlas. 


Tab.  XVI. 


Fig.  23.    Melanocarcinoma  cutis  ex  verruca. 


Rebman  Corapan}',  New- York. 


hard,  irroijnlar  honlors  are  very  marked.  The  floor  of  tlie  ulcer  is  in 
some  places  coniilied  and  is  covered  with  crusts  and  sanious  secretion. 
The  carcinoma  has  already  extended  through  the  fascia  to  tiie  bones, 
interfering  with  the  function  of  the  liand.  Tlie  glands  of  the  elbow 
and  axilla  are  li.ird  ;iiiil  nndul.ii-.  The  r.ipid  growth  of  the  tumor  has 
led  to  severe  caclicxia.  Tiiis  was  treatcil  liy  amputation  through  the 
arm  and  i*emoval  of  glands,  and  calls  for  the  same  remarks  as  Fig.  20, 
about  early  excision  of  a  scar  showing  suspicious  symptoms  of  de- 
generation. 


Fig.  23  shows  a  tumor  arising  from  a  pigmentary  wart  of  the 
sole  of  the  foot,  the  aivcohir  structure  on  microscopic  examination 
showing  it  to  lie  a  melanotic  carcinoma. 

(Com])arc  Fig.  28,  Melanosarcoma.) 

Malignant  melanotic  tumors  (sarcoma,  endothelioma  and.  more 
rarely,  carcinonui)  occur  most  frequently  in  the  skin  and  adjacent 
mucous  membranes,  and  in  the  choroid  and  iris.  In  the  skin,  they 
arise  from  pig-mented  benign  tumors,  fiat,  pigmentary  Jiicvi,  and  from 
warts  subjected  to  repeated  irritations.  Warts  on  the  sole  of  the 
foot,  the  toes  and  the  fingers  often  degenerate  in  melanosarcoma. 
A  tumor  develops,  black,  hlui.'^h.  or  hroioiish-yelloiv  in  color.  The 
skin  soon  becomes  iilcerated,  the  tumor  breaks  down  and  a  deep, 
ragged,  black  or  blue  ulcer  is  jiroduced.  A  melanosarcoma  remains 
soft.    A  melanocarcinoma  produces  an  ulcer  with  hard  edges. 

All  melanotic  tumors  are  extremely  malignant  because  they  ]irop- 
agate  and  disseminate  with  the  utmost  rapidity.  Suudl  black  nodules 
appear  in  the  neighboring  skin;  soon  the  lymphatics  are  involved, 
cachexia  develoi>s  and  a  miliary  crop  of  small  growths  is  found  at 
the  autojisy  in  must  organs,  i)articul;irly  the  lirain.  the  hnigs  and 
livei'.  Some  of  the  growths  are  full  of  pigment  as  in  the  mother 
tumoi-;  others,  younger,  do  not  yet  contain  any,  and  are  white  or 
pinkish  on  section.  The  dcjiosit  of  melanin  in  the  growth  is,  there- 
fore, secondary. 

^felanocarciimmata  may  l)e  seen  in  cliililren  as  multiple  growths 
in  the  skin  in  connection  with  xeroderma  jiigmentosum.  (See  jiage  1  ^. 
The  rapid  growth  and  frequent  hemorrhages  lead  to  severe  anemia. 

The  appearance  of  melanotic  growtlis  is  so  typical  that  no  con- 
fusion is  possible. 


25 


The  best  treatment  is  prophylaxis,  which  consists  in  the  precau- 
tionary removal  of  pigmentary  nsevi,  warts,  especially  those  that  are 
subject  to  constant  irritation.  Eepeated  cauterization  of  nsevi  and 
warts  is  to  be  condemned. 

Once  a  melanotic  tumor  has  developed,  a  radical  operation  may 
be  performed,  if  the  tumor  is  situated  on  a  limb  and  the  regional 
glands  are  not  yet  involved.  But,  in  spite  of  this  (in  the  case  repre- 
sented in  Fig.  23,  amputation  of  the  leg  and  removal  of  the  inguinal 
glands),  early  recurrence  is  the  unvarying  rule.  No  kind  of  new 
growth  possesses  as  high  a  dissemination  power  as  malignant 
melanoma. 


2G 


Bockenheimer,  Atlas. 


Tab.  XVII. 


Fig.  24.     Lymphosarcoma  colli. 


Rebman  Company,  New-York. 


SARCOMA 

Figs.  24  to  35,  iiulusivc,  i('i)iosc'iit  different  types  of  sarcoma. 

Sareoiiiata  (thus  named  from  tlioir  llcsliy  a|}|icaraiicc  nii  mm;- 
tion)  are  tumors  developed  from  connoclive  cells  and  which,  there- 
fore, may  originate  in  any  organ  containing  connective  tissue,  that 
is,  practically  everywhere  in  the  body. 

Owing  to  the  often  very  rapid  growth,  the  newly  formed  cells 
do  not  attain  complete  maturity,  so  that  the  sarcoma  consists  of 
imperfectly  developed  connective  tissue.  In  its  early  stages  it  often 
resembles,  microscopically,  inflammatory  granulation  tissue,  but  by 
its  rapid  growth  it  soon  assumes  the  character  of  a  malignant  tumor. 
The  bulk  of  the  sarcoma  is  formed  of  various  connective  tissue  cells, 
"while  the  interstitial  fibrous  tissue  is  scanty.  There  is  in  sarconta  an 
abundant  formation  of  neiv  blood-vessels,  which  is  characteristic;  so 
that  any  new  growth  accompanied  by  a  marked  collateral  circulation 
or  possessing  itself  a  great  vascularity  is  very  likely  sarcoma. 

The  transition  of  fibroma,  especially  of  such  as  arise  from  the 
connective  tissue  of  fascia,  and  of  other  connective  tissue  tumors, 
e.g.,  chondroma,  into  sarcoma  has  been  demonstrated. 

Patients  often  attribute  these  growths  to  various  injuries,  but 
there  is  no  direct  proof  of  this,  though  Phelps,  Coley,  Segond  admit 
the  possibility  of  a  causal  relation  between  both. 

Pure  sarcomata  are  classified  according  to  their  microscopic 
structure  into  round-celled,  spindle-celled  and  giant-celled  sarcomata. 
Those  formed  of  various  tissues  are  known  as  lympho-,  myxo-,  fibro-, 
chondro-,  angio-,  and  glio-sarcomata.  Pigmentary  or  melanotic  sar- 
comata are  placed  in  a  special  group. 

Clinically,  sarcomata  are  best  divided  into  soft,  many-celled, 
quickly  growing,  very  maligTiant,  easily  recurring  medullary  sar- 
coma (usually  small,  round-celled  sarcoma) ;  and  hard,  few-celled, 
slow-growing,  less  malignant  forms  (spindle-celled  and  giant-celled 
sarcoma).  In  the  first  form  the  soft  consistence  is  due  to  the  richness 
in  cells  and  the  scanty  development  of  interstitial  tissue.  As  com- 
pared with  carcinoma,  sarcoma  is  more  circumscribed  and  is  at  first 
almost  completely  encapsulated,  with  borders  as  soft  as  the  rest  of 
the  tumox". 

27 


Frequently,  owing  to  hemorrhages  and  softening  in  the  interior 
of  the  sarcoma,  cystic  cavities  are  formed  which  can  be  recognized 
by  the  presence  of  fluctuation  (Figs,  25  and  30).  Sarcomata  situ- 
ated under  the  skin  gradually  destroy  and  break  through  the  latter 
and  proliferate  on  its  surface  in  various  forms.  Fleshy  reddish- 
brown  parts  alternate  with  yellowish-white,  pulpy  parts  in  these 
tumors.  There  are  usually  blood  extravasations,  both  old  and  recent. 
The  whole  tumor  has  the  appearance  of  a  fungoid  mass  (Figs.  26,  27, 
29  and  33).  After  a  time  these  superficially  proliferating  growths 
break  down  and  become  septic,  so  that  the  characteristic  appearance 
of  the  sarcoma  is  lost,  and,  on  the  scalp  and  extremities,  for  example, 
it  cannot  be  distinguished  from  an  ulcerated  carcinoma.  As  the 
sarcoma  usually  breaks  through  the  skin  and  proliferates  on  the  sur- 
face, so  may  it  extend  into  all  the  deeper  tissues,  so  that  fijially  an 
enormous  tumor  is  formed  which  may  destroy  the  bones  (Figs.  25, 
27  and  33). 

The  second  form,  the  slow-growing,  few-celled  tumors,  resemble 
fibroma  and  often  represent  transitional  forms  (fibro-sarcoma).  The- 
latter  sometimes  occur  as  multiple  nodules  in  the  skin. 

Sarcoma  often  occurs  in  robust  people  in  middle  life  (between  30 
and  50).  Sometimes  it  is  congenital  or  appears  in  infancy  (kidneys 
and  testicles),  or  soon  after  puberty  (mammary  gland).  The  earlier 
the  tumors  appear,  the  more  malignant  they  are,  as  a  rule.  Multiple- 
sarcomata  are  seen  in  the  skin  as  pigmentary  sarcomata  (Fig.  31) 
and  in  the  bones. 

Soft  sarcomata  lead  to  metastases  much  more  frequently  than 
hard  forms.  Metastatic  deposits  are  formed  by  growth  of  the  tumor 
into  the  large  veins  and  the  formation  of  emboli,  which  are  carried 
to  the  lung,  spleen,  liver  and  brain.  Dissemination  by  way  of  the 
lymphatics  is  usually  absent.  The  latter,  however,  are  certainly  often 
involved,  especially  in  ulcerated  sarcoma,  in  melanotic  forms  and  in 
osteosarcoma. 

Sarcoma  is  accompanied  by  a  thermic  ascension,  either  general 
or  local,  or  both,  due  to  the  resorption  of  toxins. 

In  many  cases  the  body  is  so  quickly  filled  with  metastases  that 
the  patients  soon  succumb  from  severe  anemia  and  toxemia.  Unfor- 
tunately, they  often  do  not  apply  for  treatment  before  metastases^ 
render  the  condition  hopeless. 

Differential  diagnosis 

Sarcoma  may  be  mistaken  for  a  benign  tumor,  for  a  gumma, 

for  a  carcinoma.    The  latter  is  a  hard  tumor,  while  sarcoma  is  gen- 

28 


erally  soft;  however,  il  does  not  iiiiitter  if  a  mistake  be  made  in  this 
direction,  since  both  conditions  call  for  the  same  radical  surreal 
treatment. 

The  other  mistakes  aic  iiKirt'  serious:  a  bciii,i;ii  tumor  is  dis- 
ting^nished  by  its  slow  evolution;  but,  in  doubtful  oases,  it  would  be 
most  unwise  to  delay  making  a  diafrnosis  till  the  latter  has  become 
evident. 

Exploratory  incision  with  dii-cct  iiis])ectioii,  and  excision  of  a  piece 
for  inunediate  microsco])ical  examination  is  the  best  procedu7'e,  care 
being  taken  not  to  submit  the  tumor  to  unnecessary  manipulation.  It 
goes  without  saying  that  such  a  partial  excision  with  microscopical 
examination  is  only  for  those  organs  the  conservation  of  which  is 
important  (a  limb  for  instance).  In  others,  such  as  the  breast  or  the 
skin,  immediate  complete  excision  of  all  suspicious  tumors  is  indicated. 

A  gumma  may  be  mistaken  for  sarcoma ;  but  here  the  ante- 
cedent history,  the  Wassermann  reaction  and  the  quick  influence  of 
salvarsan  treatment  help  clear  up  all  doubts.  In  former  times,  the 
mistake  seems  to  have  been  frequent.  Esmnrch  claims  that  many 
growths  were  extirpated  as  sarcoma  that  might  have  been  cured  by 
autisyiihilitic  treatment. 

A  local  hyperthermia,  cvideiircd  by  the  color  of  tlie  skin  and 
the  sense  of  touch,  and  an  abundant  development  of  collateral 
venous  circulation,  ma])ping  out  a  bhiish  network  under  the  skin 
(see  Figs.  25  and  32),  are  always  particularly  suspicious  symptoms 
when  an  underlying  newgrowth  is  felt  by  palpation.  So  is  the  uitli- 
draival  of  only  pure  blood  fro)ii  a  fimior  liy  exploratory  puncture. 

Trrahnciit 

All  tumors  in  which  there  is  a  suspicion  of  sarcorrta  must  be 
removed  as  early  and  as  radically  as  possible.  lUnsi  rvative 
ojierations  have  no  i)lace  in  the  treatment  of  ordinary  spindle  or 
round-celled  sarcoma  except  as  stated  I)elow,  even  if  the  latter  seems 
still  to  be  encajisulated.  Sarcoma  of  the  limbs  demands  exarticu- 
lation  or  amputation  high  up  above  the  newgi'owth.  Recurrences  is 
very  frequent;  it  is  almost  without  exception  in  the  soft  varieties. 
The  harder  a  sarcoma,  the  fewer,  and  the  less  embryonic  in  nature  the 
cells  it  contains,  and  the  less  malignant  the  tumor;  so  that  in  the  very 
hard  varieties  of  l)one  sarcoma,  conservative  ojierations  (e.  //.,  resec- 
tion) sometimes  give  permanent  results. 

Bloodgood  goes  so  far  as  to  say  that  giant-celled  iione  sarcoma 
is  not  a  maligmmt  tumor,  and  that  it  can  be  cured  permanently  by 

29 


resection  or  scraping  followed  by  treatment  of  the  cavity  with  boiling 
water.  This  opinion  is  accepted  by  many  surgeons,  and  there  is 
no  doubt  that  this  hard  giant-celled  variety  is  at  least  comparatively 
benign. 

Many  cases  have  been  treated  by  the  X-rays.  While  some  authors 
contend  that  the  X-rays  transform  the  embryonic  cells  of  sarcoma 
into  adult  tissue,  and,  therefore,  sarcoma  into  fibroma,  others  say 
that  the  action  is  only  superficial  and  similar  to  that  caused  by  an 
intercurrent  erysipelas,  which  often  brings  about  a  temporary  shrink- 
ing of  sarcoma. 

It  is  interesting  to  note,  in  this  respect,  that  Coley,  treating  inop- 
erable cases  of  sarcoma  by  injections  of  a  mixture  of  toxins  of  the 
microbe  of  erysipelas  and  of  the  Bacillus  prodigiosus,  claims  to  have 
obtained  remarkable  results  (sometimes  permanent  cures)  in  about 
10  per  cent,  of  cases.  He  also  advises  injection  of  the  mixed  toxins 
after  operation  as  a  prophylactic  against  recurrence.  Coley  always 
begins  by  operating  largely,  and  uses  toxins  alone  only  when  opera- 
tion is  refused. 

Fig.  24  shows  an  extensive  tumor  involving  the  whole  right  side 
of  the  neck,  and  made  of  several  nodular,  irregular  formations. 
The  skin  is  broken  in  one  place,  in  other  places  it  is  thin  and  bluish- 
red  in  color.  There  is  a  fistula  discharging  a  sanious  secretion.  This 
tumor  is  a  lymphosarcoma. 

The  region  of  the  neck,  where  lymphatics  are  abundant,  is  the  seat 
of  predilection  of  three  different  malignant  processes  involving  the 
lymph  glands. 

1.  Lymphadenoma   (also  called  malignant  lymphoma,  Hoclgkin's 

disease,  pseudoleuhemia) . 

2.  Lymphosarcoma,  sarcoma  of  the  lymphoid  cells  of  the  lymph 

glands. 

3.  Sarcoma  of  the  connective  tissue  of  the  same  lymph  glands. 

The  latter  two  are  often  not  distinguished  from  one  another. 
A  hard,  diffuse,  nodular  tumor  quickly  develops  from  a  group  of 
small,  hard,  movable  glands  and  shows  its  malignancy,  especially  in 
young  individuals,  by  the  continual  formation  of  fresh  nodules  at  the 
periphery,  which  coalesce  with  the  main  tumor  and  cause  it  to  attain 
a  considerable  size.  The  imlimited  growth  into  the  neighboring 
tissues  is  characteristic.  The  capsule  of  the  gland  is  quickly  broken 
through,  a  fact  which  does  not  happen  in  other  lymph  gland  tumors 
of  the  neck.    The  cervical  fascia  is  destroyed  and  the  sterno-mastoid 

BO 


muscle  invaded.  Tlie  skin  is  at  first  reddisli,  then  l)luisli-re(l  or  liviil; 
it  tliou  hoconios  tliin  .-ukI  .i;;ivos  way  over  tlic  tumor.  The  oxposeil 
parts  oi'  llif  Imniir  rai)i(lly  lircak  down  while  tlie  sarcoma  grows  into 
the  do('i)cr  pails,  especially  into  the  internal  jugular  vein,  giving  rise 
to  fatal  organic  metastases.  Tlie  vagus  nerve  and  tiie  common  carotid 
also  become  cnsheathcd  in,  and  may  be  destroyed  by,  the  tumor. 
Dyspnea  and  dysjihagia  may  be  caused  by  pressure  on  the  larynx 
and  esopliagiis.  This  occurred  in  tlio  case  represented  in  Fig,  24. 
The  tumor  extends  downwani  intu  the  inediastinum  and  may  even 
destroy  the  vertebra". 

Dioynosis  ami  Traitim  iil 

To  recognize  that  a  tuiiKH'  of  the  neck  is  made  of  lymph  glands 
is  not  difficult.  Its  situatiun  in  regions  where  lymph  glands  normally 
exist,  and  the  palpation  of  rounded  nodules  is  sufficient.  To  decide 
what  is  the  nature  of  the  condition  is  not  so  easy. 

Lymphosarcoma  is  distinguished  from  other  lymph  gland  tumors 
of  the  neck  hif  its  rapid  f/rou-(h  in  all  directions,  its  breaking  tlirough 
to  the  exterior  and  its  fungating  masses.  But,  in  the  earlier  stages,  it 
has  no  patho,gnomonic  symptoms,  and  microscopical  examination 
itself  may  be  inconclusive,  so  that  the  nature  of  the  alTection  can  only 
be  suspected. 

Lymphad(iii>)ua  {Ifn/hil.'ni's  disease),  which  usually  begins  in  the 
neck,  consists  of  small.  iiiiilti|ile,  encapsulated  nodules,  which  do  not 
break  down  nor  extend  iiiin  the  neighl)oring  organs.  There  are  gen- 
erally also  giandiilai-  enlargements  in  the  axilla?,  groins  and  medi- 
astinum, and  eliaiiges  in  the  s]ileon  and  bone-marrow. 

TiihirciiIiHis  f/lin/ils  lesemble  llnilgkin's  disease  so  nnwh  that 
many  of  the  eases  rei)orted  as  l)eing  the  latter  have  lieen  found  either 
to  be  purely  tuberculous  or,  at  least,  to  contain  tuberculous  lesions. 
The  confusion  is  not  possible  when  there  is  a  history  of  several  years' 
duration,  other  symptoms  of  scrofula,  and  groups  of  glands  of  dilTer- 
ent  consistency,  some  hard,  some  soft,  some  Huctuating.  Hut  the 
diagnosis  is  exceedingly  dinicult — in  fact,  sometimes  not  possiiile — 
when  there  are  but  I'i'w  hard,  movable  glands  invniveil. 

SyphiUlic  aldii/ls  are  at  lirst  hard,  lalei-  on  soft  ;  but  are  not  so 
extensi\'e,  and  there  are  other  symptoms,  which  soon  clear  the  diag- 
nosis. 

Branchiogenous  ((ircinnnia  ^^'<dl,lnlnnl),  arising  from  the  re- 
mains of  the  epitheliiun  of  the  branchial  clefts,  is  very  rare  and 
ajipears  as  very  hard,  spherical  tumors  in  the  carotid  fossa. 

The  tumors  afTecting  the  sheaths  of  the  blood-vessels  of  the  neck, 

:u 


first  described  by  Langenbeck,  aad  considered  by  sonae  as  lymplio- 
sarcoma,  or  rather  as  sarcomata  of  tlie  lymph  gland  stroma  having 
involved  at  an  early  period  the  vascular  sheaths,  are  regarded  by  many 
as  periiheliomata,  that  is,  tumors  developed  from  tissue  much  resem- 
bling endothelium,  but  situated  outside  of  the  blood  vessels  (about 
endothelioma,  see  Fig.  39  and  page  48). 

Metastatic  carcinoma  and  sarcoma  can  be  diagnosed  by  the  pres- 
ence of  the  primary  tumors  (scalp,  see  Fig.  28,  esophagus,  parotid, 
maxilla).  It  must  be  said  that  lymph  gland  metastases  may  exist  in 
the  neck  while  the  primary  tumor  in  the  scalp,  a  mole  for  instance, 
does  not  show  any  apparent  activity. 

Actinomycosis  may  also  cause  hard  infiltration  of  the  neck,  but 
the  infiltration  is  diffuse  and  uniform,  not  nodular,  and  extends  over 
the  whole  region  of  the  neck.  If  there  is  a  fistula,  the  pus  contains 
the  characteristic  yellow  bodies  in  which  the  microscope  demonstrates 
the  ray-fung-us  {see  Figs.  115  and  116  and  page  175). 

The  only  treatment  of  lymphosarcoma  is  radical  extirpation,  if 
the  diagnosis  is  made  early  enough.  Even  then,  the  operation  is  very 
extensive  and  often  entails  dissection  or  excision  of  the  big  blood 
vessels  of  the  neck.  Eeeurrence  is  very  frequent.  The  results  of 
surgical  treatment  being  a  very  doubtful  compensation,  some  are  con- 
tent with  X-ray  treatment  and  high  doses  of  arsenic  internally.  One 
may  obtain  a  temporary  remission.  This  treatment  was  followed  in 
the  case  shown  in  Fig.  24,  but  without  any  noticeable  success. 


Fig.  25  shows  a  soft,  partly  fluctuating  growth  with  fungating 
borders,  which  has  beg-un  to  extend  over  both  eyes.  It  is  fairly  sym- 
metrical on  both  sides  of  the  middle  line,  a  feature  which  denotes  the 
origin  from  the  basilar  process,  in-  distinction  to  the  more  lateral 
swelling  of  retro-maxillary  tumors.  In  some  places  the  skin  is  so 
thin  that  it  appears  livid  and  transparent;  in  others  it  shows  the- 
marked  vascularity  so  often  observed  in  sarcoma.  The  tumor  is  on 
the  point  of  breaking  through. 

The  disease  was  of  ten  years'  duration.  Several  non-malignant 
polypi  had  been  removed  previously  at  intervals,  and  also  a  larger 
tumor,  after  partial  resection  of  the  upper  maxilla. 

The  lesion  now  represented  is  an  epipharyngeal  sarcoma,  or 
malignant  nasal  polypus,  which  has  grown  forward  and  destroyed 
the  whole  bony  framework  of  the  nose.  On  digital  examination  the 
whole  nasal  cavity  and  naso-pharynx  were  found  filled  with  soft,. 

32 


ickcnliciincr,  Atlas. 


Tab.  XVIII 


Pig.  25.     Sarcoma  cpipliaiynjjoale  -    Polyposis  nasi  maligna. 


Rcbm.nn  Company,  Ntw-York. 


iiililtraliii.n'  fuiiid!-  iii;isscs.  wliii'li  had  disjilari'd  llic  ]p,-ilal('  ilowiiwanl 
and  forward.  'IMic  tumor  had  also  extended  lliioui,di  tlie  base  of 
Uio  skull. 

In  tlie  naso-i)haryiix  two  kinds  ol'  ii'i'owths  claiiii  special  attention— 
Rbromata,  UMially  oiMMin-iiii;-  in  males  hetween  the  twenty-liftli  and 
tliirlielli  years,  arisinu'  from  the  basilar  process,  also  I'alled  iiaso- 
pliaryn,i;eal  ])olypi— and  sarcomata,  whii-li  appear  hetween  the  tliirt- 
ietli  and  iiftietli  years,  'rumors  arisim;  in  1  ho  spheno-iialatine  fossa 
are  sonietinies  described  separately  as  retro-maxillary  tumors,  but 
after  furtlier  extension  they  cannot  be  distin.n'uislied  from  the  two 
mentioned  above. 

Fibromata,  wliicli  occur  earlier  in  life,  generally  arise  from  the 
connective-tissue  cells  of  the  periosteum  as  pedunculated  or  sessile 
encapsulated  tumors,  which  by  extensive  growth  fill  up  all  the  spaces 
and  apertures  of  the  naso-pharynx,  especially  the  posterior  naresy 
cause  atrophy  of  the  bones  by  jirossuro,  and  break  through  into  the 
nasal  ca\ily,  maxillary  antrum  aTid  cranial  cavity.  On  account  of 
their  great  vascularity,  these  growths,  which  in  some  ])laces  often 
take  the  character  of  cavernous  tumors,  are  of  much  softer  consist- 
ency than  other  filiromata.  They  may  ulcerate  on  the  surface  and  give 
rise  to  exhausting  hemorrhages.  On  account  of  their  tendency  to 
increase  and  the  frequent  sarcomatous  degeneration,  they  are  to  be 
dealt  with  as  malignant  growths. 

In  older  individuals,  in  the  majority  of  cases,  we  have  to  do  with 
true  sarcoma,  ai'ising  from  the  periosteum  or  fascia  (malignant  naso- 
pharyngeal polypi),  wliich  extends  to  tlie  posterior  nares,  the  spheno- 
maxillary fossa,  Eustachian  tubes  and  larynx;  not,  however,  as  en- 
capsulated tumors  like  fibroma,  but  as  soft,  fungoid,  sessile,  firmly 
attached  growths  with  an  irregular  outline.  Later  on  they  grow  very 
rai)idly,  destroy  the  neighboring  bones,  and  reach  the  external  sur- 
face through  the  frontal  sinus,  nasal  cavity  and  oi-bit;  intei'iially  they 
extend  to  the  brain  (Figs.  25  and  27)- 

Disintegration  of  the  tumor  goes  hand  in  hand  with  the  increase 
in  size  and  the  patient  succumbs  from  the  results  of  hemorrliage, 
septic  infection,  anemia  and  organic  metastases. 

The  clinical  symptoms  in  (ibroma  and  in  commencing  sarcoma 
arise  fi-om  olistrui'tii)n  of  the  iiaso  pharynx.  ('ontiinial  moutli- 
bi'eathing  is  suggestive  of  disease  of  the  naso-pharynx.  Owing  to 
obsti'uction  of  the  posterior  nares  the  i^afients  snore  during  sleep; 
they  acquire  nasal  catarrh  (often  atrophic  rhinitis)  and  have  a  nasal 
voice.     As  the  tumor  grows,  obstruction  of  the  Eustachian  tubes 

33 


causes  deafness  and  pain  in  tlie  eai*;  extension  to  the  cranial  cavity 
gives  rise  to  headache,  somnolence  and  choked  optic  disk;  extension 
to  the  orbit  is  attended  by  disturbance  of  vision,  e.g.,  diplopia.  Pres- 
sure on  the  facial  and  trigeminal  nerves  results  in  paralysis  and 
severe  neuralgia. 

Diagnosis  and  Treatment 

The  diagnosis  of  these  advanced  cases  presents  no  difficulty.  The 
soft,  fungoid  consistency  of  the  whole  tumor,  the  tendency  to 

bleeding  and  the  rapid  growth  are  characteristic.  In  extensive  sar- 
coma with  commencing  disintegration  and  discharge  soft  metastases 
are  found  in  lymph  glands.  Incipient  sarcoma  can  be  recognized  by 
digital  and  rhinoscopic  examination  as  an  irregular,  rough,  infiltrat- 
ing tumor,  which  differs  from  the  nodular,  encapsulated  fibroma. 

It  is  only  in  young  individuals  that  other  conditions  can  be  con- 
founded with  true  tumors  of  the  naso-pharynx.  Bypertropliied  ton- 
sils and  extensive  adenoids  cause  somewhat  similar  symptoms,  but 
direct  examination  by  the  finger  and  rhinoscopy  will  make  the  diag- 
nosis clear.  In  very  young  children  teratomata  are  seen  (Fig.  146), 
which  may  be  mistaken  for  sarcomata  arising  from  the  basilar  process 
and  extending  to  the  face.  However,  teratomata  are  usually  more  or 
less  encapsulated  and  only  appear  on  one-half  of  the  face. 

Eetro-maxillary  tumors  manifest  themselves  at  first  by  unilateral 
pain  in  the  face,  swelling  of  the  cheek  and  fixation  of  the  correspond- 
ing maxillary  joint,  but  on  further  extension  they  cannot  be  distin- 
gTiished  from  advanced  tumors  of  the  naso-pharynx,  or  from  large 
tumors  of  the  upper  maxilla  or  orbit. 

In  large  naso-pharyngeal  tumors,  excision  of  a  piece  for  micro- 
scopical examination  is  dangerous  on  account  of  severe  possible 
hemorrhage,  and  is  useless,  because,  whatever  its  nature,  the  tumor 
will  have  to  be  removed. 

In  fact,  the  mode  of  approach  is  much  more  dictated  by  the  size 
of  the  tumor  and  its  connections  than  by  its  nature.  It  goes  without 
saying  that  the  smaller  the  tumor,  and,  therefore,  the  earlier  the 
diagnosis,  the  better  are  the  operative  conditions  (less  anemia  on 
account  of  less  frequent  hemorrhage  and  less  interference  with  blood 
oxygenation),  and  the  better  are  the  chances  of  a  complete  and  per- 
manent cure.  Consequently,  a  complete  rhinoscopic  examination 
is  indispensable  in  all  cases  of  mouth  breathing,  and  all  tumors,  even 
benign,  must  be  removed  as  early  as  possible. 

Hypertrophied  tonsils  are  removed  by  tonsillectomy,  not  simply 
partially  sliced  off  by  tonsillotomy.    Adenoids  are  scraped  away,  and 

34 


Bockenheimer,  Atlas. 


Tab.  XIX. 


E 


Rebman  Com|3aiiy,  New- York. 


not  lot't  alone  uikUt  tlie  pretense  tlial  tlicy  may  siiontaneously  disap- 
pear at  i)u1)orty. 

Small  iihromata  may  lie  romovcil  llirouyli  the  muuth  after  s]:)lit- 
ting  of  the  soft  and  i)art  of  the  hard  palate,  or  by  temporary  division 
of  the  lower  maxilla.  The  tumors  should  always  be  removed  by  in- 
cision into  healthy  tissues  with  the  knife  and  not  simply  torn  from 
their  attachment.  In  extensive  fibromata  and  in  all  tumors  suspected 
of  sarcoma,  the  naso-pharynx  must  be  freely  laid  open,  by  temporary 
resection  of  the  hard  palate  together  with  the  alveolar  process 
(Partscli),  or  by  temporary  resection  of  both  upjjer  nuixilla*  and 
upturning  of  the  nose  (v.  Bergmann).  Preliminary  tracheotomy  and 
ligation  of  the  external  carotid  on  one  or  both  sides  (Kocher,  Kijiiig), 
are  expedient  in  these  bloody  operations. 

luoi^erable  tumors  may  be  treated  by  the  X-rays,  and,  when  ulcer- 
ated, disinfected  with  moist  antiseptic  dressings.  In  the  last  stages 
tracheotomy  becomes  necessary  to  save  the  patient  from  death  by 
asphyxia. 


Fig.  26  shows  an  angiosarcoma  of  the  face.  (Compare  with 
Fig.  1,  rodent  ulcer  in  the  same  situation,  and  Fig.  31,  imiUiple  sar- 
coma of  the  skill.) 

Eound-celled  and  spindle-celled  sarcoma  of  the  face  is  rare;  angio- 
sarcoma is  more  common.  In  this  case  the  tumor  is  pedunculated  and 
is  characterized  by  its  concentric,  spherical  disposition.  The  base  of 
the  tumor  is  surrounded  by  a  ring  of  epidermic  scales.  The  sui-face 
is  red,  slightly  uneven,  not  unlike  that  of  exuberant  granulations. 
On  a  whole,  the  tumor  somewhat  resembles  a  strawberry;  it  is  of  very 
soft  consistence,  easily  bleeding  at  the  slightest  touch.  The  malig- 
nancy is  shown  by  its  rapid  growth.  It  is  distinguished  from  carci- 
noma by  the  absence  of  glandular  enlargement. 

Differential  diaynoKts 

The  tumor  resembles  in  appearance  two  diseases — frambcesia 
tropica  (or  yaws)  and  botriomycosis.  The  initial  lesion  in  yaws  is, 
however,  soon  followed  by  a  general  eruption  of  similar  franiboesi- 
form  growths,  covered  by  cheesy-like  scabs.  The  disease  is  seen  only 
in  certain  countries.  It  tends  to  spontaneous  recovery  and  heals  very 
quickly  under  salvarsan  treatment.  Botriomycosis  is  simply  infected 
granulation  tissue.  The  granular  growths  in  both  yaM's  and  botrio- 
mycosis remain  suporficial.  while  sarcoma  extends  into  the  deeper 
tissues. 

35 


In  mycosis  ftmgoides  nmltiple  growths  occur  whicli  may  develop 
into  tumors  resembling  sarcoma.     (See  page  37). 

Treatment 

Early  and  free  excision.    In  the  face  the  defect  may  be  repaired 
by  a  jalastic  ojDeration. 


Fig.  27  shows  a  very  extensive  sarcoma  involving  the  left  half 

of  the  face  and  already  extending  to  the  right  half.  Protruding 
from  the  orbit  are  fungoid  masses  characteristic  of  sarcoma  (sarcoma 
fungoides).  The  soft  edges  have  the  typical  reddish-brown  color  of 
sarcoma.  In  the  places  where  the  skin  is  destroyed,  soft  masses  with 
a  fairly  regular  surface  protrude,  which  differ  from  the  ragged,  irreg- 
ular ulcer  of  carcinoma.  The  whole  of  the  tumor  situated  in  the  orbit 
is  of  soft,  almost  fluctuating  consistency.  In  some  parts  the  fungoid 
masses  are  breaking  down  and  covered  with  sanious  discharge.  Blood 
crusts  form  on  the  ulcerations  owing  to  the  frequent  hemorrhages 
in  the  tumor.  The  brown-colored  skin  is  almost  atrophied  from  pres- 
sure of  the  tumor.  Sarcomatous  masses  protrude  from  both  nosti'ils, 
and  the  whole  buccal  cavity  and  the  naso-pharjTix  are  full  of  tumor 
masses,  which  have  caused  complete  destruction  of  the  bones  of  the 
face.  The  tumor  has  also  extended  through  the  base  of  the  skull, 
causing  extreme  drowsiness.  It  is  no  longer  possible  to  decide 
whether  it  is  a  case  of  malig-nant  naso-pharyngeal  polypus,  a  retro- 
maxillary  tumor,  a  maxillary  tumor,  or  a  periosteal  sarcoma  of  the 
orbit.  The  last  is  the  most  probable,  as  the  tumor  was  first  observed 
in  the  orbit.    Such  a  growth  is,  of  course,  inoperable. 


Fig.  28  shows  a  hard,  rough,  movable,  brownish-black  tumor  of 
the  scalp,  which  rapidly  developed  from  a  pigmentary  naevus  in  a 
man  of  19.  (Compare  with  Fig.  23.)  The  hardness  and  rajoid  growth 
reveal  a  malig-nant  tumor  the  nature  of  which  (melano-carcinoma  or 
melano-sarcoma)  can  only  be  decided  by  microscopic  examination,  for 
carcinoma  and  sarcoma  of  the  scalp  are  very  similar.  The  tumor 
has  remained  small  and  is  covered  by  unbroken,  pigmented  skin. 

The  malignancy  of  the  tumor  is  strikingly  shown  by  the  enormous 
enlargement  of  the  regional  lymphatic  glands.  Not  only  the  glands 
of  the  nape  of  the  neck,  but  also  all  the  glands  on  the  right  side  of 
the  neck  to  the  supra-clavicular  fossa  are  transformed  into  soft 
nodular  tumors.    The  consistency  of  these  glandular  tumors  is  so  soft 

36 


ckcnhciiiicr,  Alias. 


#. 


\ 


/ 


Ficr.  2S.    Melanosarconia  cutis  -   l.ymplioniata  sarcomatosa  colli. 


Ill  Company,  Nc\v-\'ork 


Bockenheimer,  Atlas. 


Tab.  XXI. 


Fig.  2Q.     Sarcoma  mammae  exulceratum. 


Rebman  Company,  New- York. 


as  to  fjjivo  the  sensation  of  lliii'liialion  I  |)siMiiln Humiliation),  wliidi  is 
charactoristic  of  rapidly  f^rowiii,!*'  sarcomatous  metastases.  The 
patient  rajiidly  snccnmhed  after  tlie  ai)pearaiice  of  metastases  in  tiie 
luii.ns,  wliicli  caused  ahundaiit  iileiiial  elTusions.  (Compare  witli  Fig. 
24.) 

The  glandular  metastases  and  innunieralile  nodules  in  the  lungs 
and  heart  were  white  in  color,  the  pigmentation  of  the  mother  tumor 
often  being  absent  in  the  rapidly  developing  metastases  of  melanotic 
tumors,  as  already  stated  on  page  23. 


Figs.  29  and  30  show  two  examples  of  Sarcoma  of  the  Breast. 

Comjiare  with  Figs.  10-16,  carciiinma  of  tlir  hn'usi.  and  85  ;iiid 
86,  inflammations  of  the  breast. 

Sai'coma  is  much  less  common  in  the  mammary  gland  than  car- 
cinoma (one  hundred  carcinomata  to  ten  sarcomata,  and  half  of  these 
eysto-sarcomata,  v.  Avgerer).  All  cell  forms  of  sarcoma  may  be 
represented  as  well  as  mixed  forms,  such  as  myxo-,  angio-,  and 
melano-sarcoma. 

They  occur  most  often  in  young  women.  According  to  their  com- 
position they  have  different  clinical  sigTis.  Spindle-celled  sarcoma 
is  of  firmer  consistency  and  of  slower  growth  than  the  soft,  malig- 
nant, round-celled  sarcoma  and  melanosarcoma.  Cysto-sarcoma  soon 
leads  to  extensive  tumors,  which  transform  the  breast  into  a  large 
sac  with  tluid  contents.  The  typical  characteristics  of  sarcoma  are 
generally  present  in  the  mammary  tumors  (Fig.  29). 

Differential  liiiigiwsis 

Carcinoma  is  distinguished  by  the  absence  of  any  demarcation 
from  the  mammary  tissue,  while  sarcoma  is  often  encapsulated. 
Moreover,  the  clinical  signs  of  carcinoma  are  so  characteristic  {cf. 
Figs.  10-16)   that  confusion  is  hardly  possible. 

Cysts  of  the  mannna  are  usually  situated  behind  the  nipple, 
multiple  (in  one  or  both  mammre),  and  not  so  large  as  true  cysto- 
sarcoma. 

Fibroadenoma,  which  originates  in  the  glandular  tissue  and  con- 
tains many  conTiective  tissue  cells,  is  the  type  of  the  slow-growing, 
encapsulated,  benign  tumor. 

The  treatment  is  extirpation  of  the  whole  nianinia  as  early  as 
possible,  with  free  exposure  of  the  axilla.  After  early  complete  opera- 
tions, local  recurrence  is  less  common  than  in  carcinoma. 

37 


Fig.  29  shows  a  rapidly  growing,  round-celled  sarcoma  in  a 

young  girl.  The  tumor  forms  a  soft,  fairly  circumscribed  nodule  in 
the  mammary  gland.  That  the  part  of  the  tumor  lying  in  the  mamma 
is  considerably  larger  than  the  external  appearance  indicates  is 
shown  by  the  prominent  veins.  As  already  stated,  this  collateral  cir- 
culation is  always  suggestive  of  sarcoma.  The  tumor  is  near  the 
nipple,  but  there  is  no  retraction  of  the  latter.  It  is  freely  movable 
over  the  pectoralis  fascia.  Externally  it  has  involved  the  skin,  which 
has  the  usual  brownish-red  color  of  sarcoma,  has  become  very  thin 
and  is  already  ulcerated  in  one  spot,  from  which  repeated  hemorrhage 
has  taken  place.  The  fungoid  tumors,  in  distinction  to  carcinoma,, 
have  a  smooth,  uniform  surface  and  resemble  exuberant  granulation 
tissue.  There  were  no  glands  to  be  felt  in  the  axilla.  The  ease  was 
treated  by  extirpation  of  the  mamma  and  free  exposure  of  the  axilla. 

Fig.  30  represents  a  cystic  tumor  occurring  in  a  young  woman, 
which  has  begun  to  displace  the  whole  breast.  There  is  no  alteration 
in  the  nipple.  The  tumor  is  movable  over  the  pectoral  fascia,  and  in 
several  places  distinctly  separate  from  the  mammary  tissue.  The 
veins  are  enlarged  from  pressure  of  the  tumor.  The  tumor  has 
already  invaded  the  skin,  which  has  become  very  thin,  and  in  some 
places  fluctuating.  The  skin  is  colored  brownish-red  and  bluish- 
green,  and  shows  a  network  of  vessels.  As  long  as  the  skin  is  intact 
it  can  never  be  definitely  ascertained,  except  by  exploratory  puncture, 
whether  we  have  to  deal  with  actual  cavities  filled  with  fluid,  or  the 
pseudofluctuation  of  gelatinous  or  mucoid  sarcoma.  Rapid  growth 
and  commencing  soft  glandular  swellings  in  the  axilla  point  to  the 
diagnosis  of  cysto-sarcoma,  which  was  treated" by  extirpation  of  the 
mamma  and  removal  of  the  axillary  glands. 


Fig.  31  shows  a  case  of  Multiple  Sarcoma  of  the  Skin  affecting- 
the  whole  of  the  thorax,  abdomen  and  back. 

In  sarcoma  of  the  skin,  all  histological  types  are  found.  It  may 
be  pigmented  (melanotic  sarcoma,  see  Figs.  23  and  28)  or  not.  It 
may  be  single  or  multiple,  primary  or  secondarj':  when  secondary, 
it  is  generally  multiple.  Next  to  true  sarcoma,  "we  find  the  lesion  first 
described  by  Kaposi  as  multiple  pigmented  hemorrhagic  sarcoma, 
but  better  named  multiple  hemorrhagic  sarcoma,  because  it  is  not 
pigmented,  the  color  being  exclusively  due  to  hemorrhage.  Next  to 
these  really  sarcomatous  groups  exists  the  group  of  Sarcoid  lesions,. 

38 


Be 


enhciiiicr,  Atlas. 


Tab.  XXII. 


Fig.  30.    Sarcoma  mammae  c)sticum. 


mail  Company,  Nc\v-\'ork. 


Bockenheimer,  Atlas. 


Fig.  31.    Sarcoma  cutis  multiplex. 


Rebinan  Company,  New-York. 


Miiioii.n-  wliicli   we   sli.ill   incntion  liocck's  Sarcnid  and  Mt/cosis  fiiit- 
guidcs,  tlic  tniL'  nature  ol'  wliicli  is,  as  yet,  unknown. 

Multiple  sarcoma  of  the  skin  always  appears  in  a  cliai  ai'leristie 
I'oi'ni,  as  rod  saints,  wliicli  soon  liccmnc  ikuIhIcs.  'i'lic  nii(liilc<  increase 
ill  size  and  liccoinc  rniilliiciil .  Ilin>  rnniiiiii;'  a  liinidr  wliicli  is  at  first 
iiiovalilc  over  llic  iiiidcrix  iiii;'  ti>>ii('>.  I.alcr  on  IIh'  skin  d('S(|nainates 
and  hoconios  red,  liliii>li  (ir  li\id,  then  Innwncr  after  rcpoatod  liemor- 
jia.n'cs,  and  may  linnll>'  iili-crate.  The  <\<\\\  dv-cr  iiiuincntary  sarconiata 
is  liluish  black".     (Figs.  23  and  28.) 

Besides  the  ulceration  oi  tiie  no<lules,  spontaneous  resolution  is 
jiossible,  complete  or  partial,  leavinij-  a  cicatrix.  The  nodular  tumors 
may  in  some  cases  remain  the  same  size  for  years.  The  tumors  are 
always  circumserihed,  and  are  of  soft  or  lirm  consistence  according 
to  tlieii-  composition.  Soft  nodules  tend  to  disintegration,  hard  nod- 
ules to  atrophy  and  cicatrization.  The  former  are  very  malignant  and 
soon  lead  to  death  from  glandular  and  oriianic  metastases;  the  latter, 
Iiy  their  multiplicity,  after  some  years  cause  cacJiexia,  which  with  me- 
•tastases  leads  to  a  fatal  issue.  This  happened  in  the  case  shown  in 
Fig.  31,  wliere  some  of  the  cicatrices  left  In-  previously  existing  nod- 
ules ina>'  lie  seen.  Cachexia,  however,  kept  on  progressing  till  death. 
The  skin  III'  the  whole  hody  between  the  nodules  is  often  of  a  dirty 
sallow  cohir  (Fig.  31).  Small  spots  and  elevations  on  the  skin  point 
to  the  develo))ment  of  fresh  sarcdinatuus  nodules. 

Multiple  hemorrhagic  sarcoma  appears  in  the  form  described 
above,  but  first  of  all  on  the  lower  extremities,  in  the  form  of  reddish 
nodules  which  often  cause  much  itching.  Tumor  formation  goes  hand 
in  hand  with  edematous  iufiltratimi  which  extends  over  the  whole  leg 
and  prevents  the  patient  from  walking.  Desquamation  of  the  skin 
on  the  surface  of  the  nodules  occurs  along  with  coruification  of  the 
e]udermis.  Cicatrices  form  in  the  skin  from  atrophy  of  the  nodules. 
Other  regions  of  the  body  are  unaffected,  except  the  peripheral  jiarts 
of  (he  iip]ier  extremity,  'i'liere  is  no  enlargement  of  the  lymi)hatic 
glamls.  The  disease  runs  a  proiiicssive  course,  and  in  sjiite  of  th& 
spontaneous  resolution  of  some  df  (he  tnnmrs.  linally  causes  death  by 
marasmus.  The  average  duiatitm  is  about  5  years,  Init  some  cases 
lin\-e  been  followed  for  20  to  .">()  years. 

^Microscopic  examination  siiows  a  pure  sarcoma  with  abundant 
blood-vessels,  which  often  gives  rise  to  organic  metastases.  As  tlii;* 
form  occurs  often  in  old  peojile,  arteriosclerosis  may,  perhaps,  play 
a  part  in  the  origin  and  course  of  the  disease. 

39 


Differential  diagnosis  and  Treatment 

Primary  multiple  sarcomata  must  not  be  mistaken  for  secondary 
sarcomatous  growths  in  connection  with  a  primary  cutaneous  sar- 
coma or  a  sarcoma  of  the  internal  organs.  So  a  careful  search  must 
always  be  made  for  a  possible  primary  tumor.  The  tumors  of  myco- 
sis fungoides  are  more  likely  to  be  mistaken  for  sarcoma,  as  they 
also  develop  from  red,  uneven  spots,  and  form  granulation  tumors 
of  a  brownish-red  color  which  in  the  later  stages  tend  to  ulceration 
and  cachexia ;  but  mycosis  fungoides  is  of  much  slow6r  growth  than 
sarcoma  and  there  generally  coexist  in  different  parts  of  the  body  of 
the  same  patient  the  three  different  stages  of  mycosis  fungoides, 
namely,  the  premycotic  itching  patch,  the  infiltration  and,  finally,  the 
fungating  lesion.  The  association  of  these  three  types  of  lesion  is 
characteristic.  Syphilitic  and  tuberculous  granulomata  can  hardly 
be  taken  for  sarcoma  on  careful  examination. 

Carcinoma  of  the  skin  is  clinically  so  different  from  multiple 
sarcoma  that  no  hesitation  can  arise,  except  for  the  melanotic  form, 
which  can  be  distinguished  only  by  microscopical  examination. 

Preventive  treatment  of  multiple  sarcoma  consists  in  the  removal 
of  all  nasvi  which  begin  to  take  on  rapid  growth.  In  already  existing 
multiple  pigmentary  sarcoma  excision  is  generally  useless,  and 
should  only  be  performed  when  the  tumors  are  very  few  in  number 
if  not  single,  and  the  blood-vessels  free  from  melanin.  After  excision 
of  multiple  sarcomata,  especially  melanosarcomata,  death  often  fol- 
lows from  rapid  dissemination  and  organic  metastases.  Hence  the 
X-rays,  large  doses  or  arsenic  (internally  or  subcutaneously)  have 
been  employed  for  multiple  cutaneous  sarcoma,  in  the  same  way  as 
for  mycosis  fungoides.  They  have  given  temporary  improvement. 
A  permanent  cure,  however,  is  not  to  be  expected  and  the  prognosis 
of  these  multiple  sarcomata  is  always  bad. 


Fig.  32  shows  a  peripheral  sarcoma  of  the  upper  end  of  the 

humerus  in  a  young  individual. 

The  soft  tumor  has  extended  under  the  skin,  in  which  the  brown 
coloring  and  extensive  network  of  dilated  veins  are  very  marked. 
The  lower  borders  of  the  fusifonn  tumor  are  irregular  and  send 
processes  here  and  there  into  the  muscles.  The  tumor  has  destroyed 
the  head  of  the  humerus  and  has  broken  through  into  the  joint,  in 
which  there  is  an  effusion.  The  function  of  the  joint  and  upper  arm 
is  destroyed.    The  supra-clavicular  glands  are  enlarged.    Posteriorly 

40 


lab.  XXIV. 


Fig.  32.     Sarcoma  liumcri  |-icriplicricum. 


ibniaii  Comp.iny,  New-York. 


the  linnor  hns  oxtoiidcil  In  tlic  sc.-ipul.-i  rci^inii.  Tlic  X-r;iys  sliow 
complete  destruction  of  (he  ii|>i>cr  |i.iii  of  liic  ImnnTiis. 

I)i)ii('  sarcoiiiii  is  one  ol'  tiic  nm>t  inipDrl.-int,  ;in(l  l'rc(|U('iit  varieties 
(if  sai'conia. 

( )sleo-sareoniata  are  l)e.st  divided  into  peripheral  and  central;  the 
latter  may  arise  from  the  cortical,  sponyy  or  medullary  ])ortions. 
Division  into  periosteal  and  myelog-enous  tumors  is  clinically  impos- 
sible, and  the  word  mycloiienous  may  be  rejilaced  l)y  osteal.  Tumors 
wliicb  appeal-  clinically  tii  be  pci'iosteal  often  arise  from  tlie  super- 
licial  layers  ol'  tlic  cnrtcx.  Tlic  X-rays  enable  easily  to  divide  them 
into  peripheral  and  central  tiiiiiors;  tbis  leaves  npeii  the  possible 
orijrin  of  the  sarcoma  from  any  jiart  of  the  bone,  and  this  can  only  be 
conclusively  settled  by  section  of  the  bone  after  removal.  This  classi- 
fication is  all  the  more  rational  because  sections  of  specimens  which 
were  clinically  regarded  as  i)eriosteal  sarcomata  show  that  these 
arose  from  small  foci  in  the  medullary  cavity.  Periosteal  tumors 
may  extend  into  tlie  medullary  cavity  and  so  sinuilate  osteal  tumors. 
In  extensive  tumors  tlie  origin  of  the  tumor  from  any  definite  ]iart  of 
the  bone  cannot  as  a  rule  be  established. 

Both  forms  have  special  seats  of  predilection:  in  the  long  bones, 
the  neighborhood  of  the  epiphyses  e.g.  tlie  upper  end  of  the  humerus 
(Fig.  32),  the  lower  end  of  the  femur,  especially  the  internal  con- 
dyle, the  head  of  the  tibia,  the  lower  end  of  the  radius;  the  Hat  bones, 
especially  the  scapula  and  bones  of  the  skull.  Both  forms  also  grow 
in  a  globular  type  involving  the  whole  circumference  of  the  bone 
and  tinally  its  whole  thickness.  They  aii]iear  at  ]niberty  and  during 
the  whole  period  of  growth,  generally  in  young  and  rolnist  individ- 
uals. 

Both  kinds  soon  lu-eak  through  their  own  cajisule  and  that  of  the 
bones  and  then  extend  sometimes  into  the  neighboring  joints,  often 
into  the  muscles,  especially  the  muscular  insertions  into  the  bones, 
and  into  the  veins,  eventually  forming  enormous  tumors  which  break 
through  the  skin  and  protrude  as  riingoid  masses.  The  sn])erlicially 
situated  tumors  have  a  teinleiicy  to  ri-i'i|iieiil  lieinorrliage  and  destruc- 
tive inflammation. 

Microsco]iically,  spuidle  ccUk  are  often  found  in  ix  I'lpheiul  aar- 
coma,  and  rj'xnit  cells  in  centred  sarconin.  The  other  forms  of  sar- 
coma cells  are  also  ]iresent. 

The  X-rays,  in  peripheral  sarcoma,  show  little  cliaime  in  the  cor- 
tex. In  central  tiiinors.  es|iecially  those  arisiiii;'  IVoni  the  iiiediillary 
cnvity,  they  often  show  spherical  transpareiil  .-paces  in  the  interior, 

II 


while  the  cortex  is  very  thin  and  excavated — forming  a  shell — in  the 
same  way  as  in  bone  cysts,  osteomyelitic  abscesses,  isolated  tubercu- 
losis and  gumma. 

Dingn  osis 

In  the  early  stages  the  diagnosis  of  osteo-sareoma  is  difficult.  The 
peripheral  tumors  are  naturally  easier  to  recognize,  as  they  present  a 
rapidly  growing  mass,  firmly  attached  to  the  bone,  with  irregailar 
boundaries  toward  the  muscles.  Eheumatic  pains  and  effusion  into 
the  joints  frequently  occur  when  the  tumors  are  situated  near  the 
joints.  The  nearer  the  sarcoma  comes  to  the  skin  the  easier  it  is  to 
palpate  the  superficial  tumor  masses,  which  infiltrate  the  soft  tissues, 
and  consist  of  cells  only  without  bony  infiltration.  Sivelling  of  the 
cutaneous  veins  occurs  early  from  pressure  of  the  tumor  on  the  ves- 
sels, while  the  skin  becomes  reddish  brown,  thin  and  almost  trans- 
pjarent,  especially  when  the  tumor  is  adherent  to  it.  These  two  feat- 
ures are  clearly  visible  in  Fig.  32. 

Slow-growing  central  sarcomata  can  at  first  be  diagnosed  only  by 
the  X-rays,  later  on  they  present  themselves  as  hard  spheroidal  swell- 
ings like  billiard  balls.  The  more  they  extend  and  approach  the  skin, 
the  thinner  becomes  their  bony  shell,  which  finally  gives  the  sensation 
of  parchment  crepitation,  first  described  by  Dupuytren.  Central 
tumors  are  often  first  diagnosed  by  the.  occurrence  of  spontaneous 
fracture.  Extensive  forms,  which  assume  a  more  spindle-celled  for- 
mation are  easy  to  recognize.  Through  growth  of  the  txmior  into  the 
joints  and  muscles,  typical  functional  derangements  are  produced, 
and  separation  of  the  epiphyses.  Metastases  in  the  lungs  develop 
early.  Disintegration  of  the  tumor  cells  gives  rise  to  fever,  espe- 
cially in  rapidly  growing,  small,  round-celled  sarcomas. 

Parostecd  sarcoma  is  easily  mistaken  for  pei'ipheral  sarcoma,  and 
is  often  impossible  to  disting-uish  by  the  X-rays.  It  is  often  of  very 
soft  consistence,  and  was  formerly  called  encephaloid. 

Chondrosarcoma  only  occurs  in  the  neighborhood  of  the  joints 
and  forms  irregular  nodular  tumors  (Fig.  34). 

Sarcoma  situated  near  the  large  vessels  and  pulsating  with  them 
may  be  mistaken  for  aneurism,  but  the  X-raj's  will  assist  the  diagno- 
sis. Central  sarcomata  have  been  wrongly  considered  as  aneurism 
of  the  bone,  owing  to  their  vascularity  and  their  reddish-brown  color 
on  section,  which  is  due  to  frequent  hemorrhages. 

Myelomata  are  multiple,  occur  chiefly  in  the  vertebrje,  and  albu- 
mose  is  found  in  the  urine. 

43 


Metastatic  carclnoiua,  which  (iccui'^  f,-|icci;illy  in  tliu  neck  nl'  the 
femur  after  mammary  carfiiioina  in  wdhicm.  ;iii<1  in  tlie  head  of  the 
humerus  after  rnrcinonia  df  Ihc  lliyroid  ;4l;in(l  ( /■.  Eiselsherg),  must 
be  diagnosed  l)y  Ihc  ]M-iiii;iry  -inwlh. 

Osteo-sarcoma  may  i)()ssii)|y  ht'  inistai\t'ii  I'or  arthritis,  rheuma- 
tism, osteomyelitis,  syphilitic  and  tithcrciiloiis  [jrocesses;  but  in  most 
cases  the  dia.i>nosis  can  l)o  made  l)y  careful  clinical  analysis,  by  the 
history  of  tlie  case,  l)y  the  X-rays,  by  anti-syphilitic  treatment,  and 
in  osteomyelitis  by  searcli  for  hemolysin  (Brack,  Michaelis,  Schultze). 
Uninterrupted  increase  of  a  diffuse  <ii-o\vfii  should  always  raise  the 
suspiciiin  of  iiialii^iiaiil  tumor.  In  ildulitrui  cases  an  exploratory 
incision  must  be  made. 

In  all  eases  the  progTiosis  is  very  ])ad.  The  liarder  forms  of  sar- 
coma (spindle-celled  and  giant-celled)  sometimes  have  a  better  prog- 
nosis, particularly  the  giant-celled,  which  Bloodgood  considers  as 
non-malignant.  Soft,  round-celled  sarcomata  are  the  most  malig- 
nant on  account  of  their  rapid  growtli  and  early  metastases. 

Trent  mi, 1 1 

The  earlier  operative  treatment  is  undertaken,  the  more  likely 
is  a  radical  cure. 

Small,  central  sarcomata  can  lie  removed  by  the  chisel,  and  the 
medullary  cavity  scraped,  i)art.icularly  in  the  giant-celled  variety. 
Larger  circumscribed  tumors  still  confined  to  the  bone  can  be  re- 
moved by  free  resection  of  bone,  very  wide  of  the  limits  of  the  tumor. 
The  defect  can  be  repaired  by  bone  grafting  (auto-  or  hetero-plastic). 
But,  except  for  giant-celled  sarcoma,  conservative  operations  are  not 
advisable. 

If  the  sarcoma  has  already  invaded  the  muscles,  high  amputation 
or,  preferably,  exarticulation,  must  lie  performed. 

Inojierable  sarcoma,  is  to  be  treated  according  to  the  rules  for 
inoperable  tumors.     (See  page  4.) 

In  the  case  represented  in  Fig.  32,  as  thei-e  was  no  evidence  of 
organic  metastases,  the  arm  and  shoulder  girdle  (scapula  and  outer 
half  of  the  clavicle)  were  removed  after  section  through  the  middle 
thiiil  of  the  clavicle  and  ligation  of  the  subclavian  artery  and  vein. 
(Ii/ti  rscapalothnracic  amputation.)  The  axillary  and  snpra-cla\'ic- 
ular  lymph  glands  were  also  removed. 

On  section,  the  whole  of  the  uiijier  portion  of  the  Inuuerus  was 
found  to  be  transfoi-med  into  a  large  tumor,  the  central  parts  of 
which  were  hard  from  bony  infiltration,  while  the  periphery  was 

43 


soft  and  fungoid.    The  tumor  was  a  round-celled  sarcoma,  but  it  was 
too  extensive  to  decide  from  wliicli  part  of  the  bone  it  originated. 

Fig.  33  shows  a  rapidly  growing,  recurrent,  ulcerated  sarcoma 
of  the  fascia  of  the  arm.  The  younger  nodules  are  covered  by  livid 
skin,  which  is  intact  in  some  parts  and  thin  in  others.  In  other  parts 
there  are  white  cicatrices  left  by  former  operations.  The  X-rays 
show  that  the  sarcoma  has  extended  to  the  bone.  Owing  to  the 
growth  having  broken  into  the  elbow  joint,  this  is  immobilized  in  a 
right-angle  position.  There  are  some  small,  soft,  enlarged  glands  in 
the  axilla. 

Fascia  and  sheaths  of  blood-vessels  are  often  the  starting  point 
of  sarcoma ;  not  only  of  pure  round-celled  and  spindle-celled  sar- 
coma, but  more  often  of  mixed  forms — myxosarcoma  and  fibrosar- 
coma. Fibrosarcoma  is  characterized  by  its  tirm  consistence  and 
slow  growth;  it  is  frequently  circumscribed  and  partly  encapsulated. 
Myxosarcomata  are  characterized  by  their  softness  and  rapid  growth 
without  encapsulation.  Pure  sarcomata  appear  as  soft,  many-celled, 
rapidly  growing  tumors,  or  in  a  harder  form  which  is  of  slower 
growth  and  not  so  maligTiant. 

In  the  early  stages  of  fascial  sarcoma  (fascia  of  the  arm,  thigh, 
abdomen)  we  find  small  tumors  fixed  to  the  fascia,  but  movable  over 
subjacent  tissues  and  under  the  skin.  The  skin  is  soon  involved  and 
becomes  tightly  stretched  over  the  tumor  and  pigmented,  and  finally 
the  tumor  breaks  through  it.  At  the  same  time  the  muscles,  and  event- 
ually the  whole  region,  are  infiltrated  with  tumor  substance  (bones, 
joints,  peritoneal  cavity).  The  chief  growth,  however,  takes  place 
on  the  external  surface  in  the  form  of  nodular  fungoid  vegetations, 
which  exhibit  all  the  characteristics  of  sarcoma.  They  are  of  soft  con- 
sistency, both  in  the  center  and  at  the  peripheiy ;  the  surface  is  much 
smoother  than  in  carcinoma,  bleeds  easily  on  account  of  its  vascu- 
larity, and  is  covered  with  sanious  discharge.  Nodules  succeed  one 
another  till  an  enormous  cauliflower  growth  is  formed  (Fig.  33). 

Ulceration  of  the  tumor  is  followed  by  regional  glandular  metas- 
tases, organic  metastases,  fever  and  severe  anemia. 

Differential  Diagnosis 

These  rapidly  growing  malignant  tumors  are  so  typical  in  their 
situation  and  development  that  it  is  only  on  the  scalp  that  they  can 
be  mistaken  for  ulcerating  carcinoma.  Sarcoma  of  the  scalp  often 
has  hard  borders  with  deep  fissures  as  in  carcinoma,  and  also  gives 
rise  to  early  glandular  enlargement. 

44 


ckenheiincT,  Atlas. 


Tab.  XXV. 


Dniaii  Company,  New-York. 


Tab.  XXVI. 


Bockenheimer,  Atlas. 


FiP.  34.     Chondromyxosarcoma  -  Exostoses  malignae. 


Rebman  Company,  New-Yorl<. 


Treatment 

Small,  slqw-gi-owiiii;'  sarcoiiiatii  ciiii  lie  ivnidxcd  liy  I'reo  exfision, 
but  local  rocurreiH'e  is  l're(|ueiit.  In  extensive,  and  especially  in 
ulcerated,  tumors  of  the  extremities  am))utation  is  indicated.  Tumors 
which  arise  in  the  abdominal  fascia  Dltcii  liccome  in()))eral)lc  dwint^ 
to  extension  to  the  jieritoneal  cavity.  In  tlic  case  shown  in  Fig.  32, 
the  arm  was  amimlatetl  and  the  axilla  cleaned  of  lymphatic  izflands. 


Fig.  34  shows  a  nodular  tumoi'  of  almost  hony  hardness  arising 
from  the  tibia.  Some  portions  of  the  tumor,  however,  are  soft.  The 
tumor  has  pushed  forward  under  the  skin,  which  has  become  thin  and 
livid,  and  is  ulcerated  in  some  jilaces  throu.oh  which  the  tumor  is  be- 
g'innin.o'  to  dischari>e.  The  movements  of  the  knee  .joint  are  very 
limited.  No  s'landular  or  organic  metastases  were  found.  This 
tumor,  when  removed,  was  found  to  be  a  chondromyxosarcoma. 

Choiidrosarcomafa  are  situated  on  or  neai'  joints.  Most  fre- 
cpiently  they  arise  from  the  head  of  the  tibia  or  the  upper  end  of  the 
humerus,  also  from  the  lower  end  of  the  radius.  They  may  also  origi- 
nate from  previous  diondromata  of  the  phalanges,  metacarpal  and 
metatarsal  bones.  They  generally  form  large,  nodular,  liard  tumors 
consisting  of  hyaline  cartilage,  osseous,  mucoid  and  sarcomatous  tis- 
sue and  contain  cystic  cavities  due  to  softening  and  hemorrhage. 
They  then  resemble  in  appearance  benign,  cystic  chondrofiliroma. 

They  often  form  rajiidly  growing  tumors  which  destroy  the  bones 
and  joints  and  give  rise  to  sarcomatous  metastases  containing  no 
cartilage.  Their  prognosis  is,  therefore,  very  bad.  In  young  indi- 
viduals they  cause  disturbance  in  gi-owth  (shortening,  etc.).  S])on- 
taneous  fractures  are  frequent  in  the  forms  which  show  an  abundant 
development  of  sarcomatous  tissue  and  much  cystic  degeneration. 
Chondrosarcoma  may  also  develop  in  chondroma  arising  from  carti- 
laginous exostoses,  which  are  due  to  arrested  develoimient  of  the 
skeleton  and  disturbances  in  growth. 

These  tumors  are  so  tyjucal  that  they  cannot  be  mistaken  for  other 
growths  when  they  have  attained  a  certain  size.  On  the  contrary, 
when  small,  their  nature  may  be  suspected,  but  rarely  decisively 
allirmed,  as  they  then  much  resemble  exostoses. 

All  exostoses  and  chondromata  which  show  signs  of  rapid  growth 
must  be  removed.  In  sarcomatous  tumors,  removal  of  the  growth 
may  be  attempted,  if  the  neighboring  parts  are  not  too  involved.  In 
large  tumors,  amjuitation.  and  chiefly  exarticulntion.  are  necessary. 

•I.") 


Fig.  35  shows  a  soft  tumor,  the  size  of  a  cherry,  arising  from  the 
alveolar  border  of  the  first  right  bicuspid  tooth,  in  a  young  woman, 
and  which  has  grown  rapidly  during  pregnancy.  On  the  surface  is  a 
pin  point  ulceration  from  which  frequent  hemorrhage  has  occurred. 

This  tumor  is  an  epulis,  which  name  has  been  given  to  sessile  or 
pedunculated  fibrosarcomata  with  numerous  spindle  and  giant  cells, 
arising  from  the  periosteum  or  alveolar  connective  tissue  of  the  upper 
and  lower  jaw.  They  are  hard  or  soft  according  to  their  histological 
constitution,  with  a  smooth  surface  covered  by  mucous  membrane,  of 
rounded  form  and  the  size  of  a  walnut.  In  women  they  grow  rapidly 
during  pregnancy.  They  seldom  ulcerate.  In  children  and  young 
people  they  occur  equally  in  both  sexes.  They  often  arise  in  the 
spaces  between  the  teeth,  and  then  bear  the  imprint  of  the  neighbor- 
ing teeth  on  their  surface.  They  sometimes  develop  from  the  lateral 
surface  of  the  alveolus  and  then  grow  over  the  teeth,  usually  the 
molars,  which  they  may  loosen.  They  are  very  vascular  and  bleed 
easily,  but  cause  no  other  trouble. 

These  tumors,  although  sarcomatous,  have  usually  a  good  prog- 
nosis, for  their  growth  remains  circumscribed,  rarely  involves  the 
bone  and  gives  rise  to  no  glandular  or  organic  metastases.  They  only 
assume  a  malig-nant  character  by  their  frequent  recurrence  after  in- 
complete operations. 

Diffci  Diagnosis  and  Treatment 

Polypi  of  the  gums  {gum  boils)  arising  from  alveolar  fistula  and 
bad  teeth  do  not  attain  the  size  of  epulis.  The  flaccid  fibromata  of 
the  gum  seen  in  leontiasis  ossea  do  not  form  globular  tumors,  and  are 
only  slightly  vascular. 

Carcinoma  occurs  at  a  later  age,  seldom  arises  from  the  alveolar 
border,  and  can  easily  be  recognized  by  its  hard  borders,  fissures,  and 
metastases. 

Epulis  sliould  never  lie  simply  snipped  off  ivitli  scissors.  The  ad- 
joining part  of  alveolar  border  should  always  be  chiselled  away.  This 
was  done  in  the  case  represented  in  Fig.  35.  After  such  a  removal, 
recurrence  is  rare :  on  the  contraiy,  it  is  frequent  after  simple  ex- 
cision of  the  growth  without  bone  removal. 


4fi 


Roc 


iheimer,  Atlas. 


Tab.  XXVII. 


U 


in. 


n  Company,  New-\'ork. 


MIXED  AND  BENIGN  TUMORS 

Fig.  36'  slii>\vs  ,111  ciiciii-ulalid  cavernous  hemangioma  of  the 

tongue  developed,  after  puherly,  from  a  previous  coui>'enital  siiiiijle 
lieiiiaii.:;ionia,  a  sli.^litly  raised  red  spot  whieh  often  remains  un- 
nolieed.  This  is  tlie  most  common  secpieTice.  Siieli  a  cavernous  an- 
gioma may  also  oecnr  as  a  cong-enita!  tumor  wliieii  l)ecomes  fully  de- 
veloi)ed  in  adolescence  or  sometimes  later,  and  extends  more  deeply 
than  simple  hemangioma  into  the  mucous  membrane  and  sub-mucous 
tissue.  The  tumor  consists  of  new  blood-vessels,  especially  capil- 
laries, and  cavities  lined  by  endothelium  and  filled  with  blood. 

Cavernoniata,  as  a  rule,  present  themselves  as  bluish,  glistening 
tumors  with  several  small  nodular  jirojections  on  the  surface.  The 
mucous  membrane  in  the  region  of  the  tumor  is  so  thin  that  a  dark 
fluid  nuiss  appears  to  be  seen  through  it.  Apart  from  this  charac- 
teristic a])pearance,  the  softness  of  the  tumor,  and  the  fact  that  it 
can  be  emptied  bj'  pressure  and  made  tense  by  bending  the  head  are 
noteworthy  features.  The  growth  consists  of  cavernous  tissue,  such 
as  is  found  normally  in  the  corjiora  cavernosa  penis,  and  on  this  ac- 
count the  name  erectile  tumor  has  been  applied  to  it.  Besides  the 
superficial  growth  there  is  also  a  deeper  one  into  the  mucous  mem- 
brane, so  that  the  wliole  tongue,  the  floor  of  the  mouth,  the  soft  palate, 
the  lips  and  the  cheeks  may  be  involved.  Eventually  the  tumor  may 
implicate  the  whole  side  of  the  face  and  extend  through  the  orbit  to 
the  brain.  In  other  cases  the  tumors  are  encapsulated.  Sometimes 
there  are  multiple  encapsulated  cavernomata  lying  close  together,  but 
without  any  direct  connection.  Tumors  which,  starting  from  the 
buccal  mucous  membrane,  come  to  bulge  under  the  skin  of  the  face, 
give  rise  to  thinning  and  a  bluish  glistening  coloration  of  the  latter. 
Apart  from  the  deformity  large  cavernomata  are  dangerous,  as  they 
may  rupture  and  cause  ]irofuse  and  sometimes  fatal  hemorrhage  (as 
often  occurs  in  cavernomata  of  internal  organs,  alimentary  canal 
and  liver).  Sometimes  ulceration  occurs  at  the  points  of  rupture, 
which  may  cause  gciicral  scjilii'  iiifcctidii.  and  in  tlic  Inugui'  acute 
glossitis  and  edema  of  the  glottis. 

iKor  other  lesions  of  the  tonj;ue,  see  Figs.  6,  7,  8,  g,  118,  119,  120. 


47 


Differential  Diagnosis 

Cavernous  lymphangioma  (see  Fig.  145)  is  composed  of  larger 
protuberances  and  has  a  greenish  surface.  Moreover,  lymphan- 
gioma, though  diminished  hy  pressure,  remains  independent  of  the 
circulation  and  is  not  increased  by  bending  the  head,  stooping  or 
coughing.  As  the  result  of  inflammatory  changes,  hard  nodules  form 
in  these  tumors,  which  are  disseminated  in  the  soft  parts.  Sarcoma 
of  the  tongtte  is  rare  and  can  generally  be  recognized  by  its  smooth 
surface  and  rapid  growth.  Retention  cysts  of  the  mucous  membrane 
of  the  tongue  are  smaller,  circumscribed,  and  have  a  uniform  surface. 
On  the  other  hand,  they  are  also  covered  by  thin,  bluish,  glistening 
mucous  membrane. 

Treatment 

Cavernous  hemangiomata  can  be  extirpated  if  they  are  encapsu- 
lated. Diffuse  forms  may  be  incised  and  scraped,  after  which  the  big 
vessels  are  ligated,  and  the  inside  of  the  cavity  treated  by  boiling 
water  or  the  cautery  and  packed.  If  there  is  a  recurrence,  the  pro- 
cedure must  be  repeated. 

Inoperable  tumors  are  best  treated  with  injections  of  alcohol,  or 
with  Payr's  magnesium.  Both  methods  aim  at  thrombosis,  after 
which  shrinking  of  the  tumor  takes  place.  Injections  must  be  made 
deeply  under  the  mucous  membrane  to  avoid  necrosis,  and  are  not 
absolutely  devoid  of  danger.  For  the  treatment  of  simple  heman- 
gioma, see  p.  104. 


Fig.  37^  shows  the  right  breast  of  a  woman  (at  the  menopause) 
much  more  projecting  than  the  left.  The  upper  half  of  the  right 
breast  is  involved  in  a  tumor,  the  irregular  surface  of  which  can  be, 
recognized  by  the  bulging  of  the  skin.  The  skin  is  thin  and  reddened. 
The  tumor,  which  was  at  first  remote  from  the  nipple  in  the  inner 
and  upper  quadrant  of  the  breast,  has  grown  toward  the  nipple  with- 
out causing  retraction.  It  is  completely  encapsulated,  freely  movable, 
and  of  moderately  hard  consistency.  It  was  removed  through  a  ra- 
dial incision,  together  with  the  adjacent  mammary  tissue,  and  micro- 
scopical examination  confirmed  the  clinical  diagnosis  of  cystic  fibro- 
adenoma already  established  by  the  above-mentioned  signs. 

Real  adenoma  and  piire  fibroma  are  rare  in  the  breast.  Myxoma, 
angioma,  chondroma  and  mixed  tumors  are  very  rare.     Fibro-ade- 

iCompare  with  Figs.   10-16    (eaveinonia  of  the  breast),  2g<aiid  30  (sarcoma),  85-86 
(inflammations). 

4-8 


15(  :enlieiiiier,  Alias. 


Tab.  X.Will. 


noma  iw  Hie  only  l)eiii.<i:n  tumor  of  tlio  breast  deserving?  consirlora- 
tioii,  (111  aocouut  oi'  its  <'oini)arativo  rro(|uenoy. 

Filtro-adc'iioiua  usually  dcvc'lojis  in  the  peripheral  portions  oi'  the 
nianiniary  .n'land  in  youn,i>-  wouion,  as  a  slow-,u;rowin.i!:,  nodular  tninor, 
so  well  encapsulalcij  tli.il  if  is  IVccly  movable  witliin  the  l)r('ast. 
Tumors  of  this  t>|u'  inc  r.irdy  niiiltipie  and  seldom  aifeet  both 
breasts.  \\'h('n  IIh'it  is  ,111  aliuinl.iiit  development  of  connective  tis- 
sue the  tumors  are  lirm;  when  cystic  cavities  develop  they  are  soft 
and  fluctuating  {cystic  fihto-adenoma). 

The  tumor  desci'ibed  as  cystadenoma  papilliferum,  or  intracanali- 
cular  lihroma,  which  is  formed  by  connective  tissue  processes  covered 
by  ei)ithelium  projecting  into  the  cavity  of  the  cyst,  belongs  to  the 
grou]i  of  benign  mannnary  tumors.  In  older  women,  especially  at  the 
menopause,  small  multiple  cystadenomata  occur  chiefly  in  the  region 
of  the  nipple,  without  causing  retraction;  sometimes  in  both  breasts. 
These  feel  like  solid  tumors  owing  to  their  thickened  walls.  The 
name  of  clironic  cystic  interstitial  mastitis  has  been  given  to  these 
tumors  by  Ku)iig,  and  that  of  " ci/stic  disease  of  the  breast"  by  many 
authors. 

The  benign  nature  ol'  those  tumors  is  shown  l)y  the  fact  that  they 
ordinarily  cause  neither  glandular  nor  organic  metastases.  On  the 
other  hand,  these  tumors,  especially  cystic  fibroadenoma,  after  slow 
increase  in  size  may  become  enormous  growths,  as  large  as  a  man's 
head,  and  then  cause  much  inconvenience  by  their  weight,  and  also 
radiating  pains  in  the  arm.  Moreover,  there  is  a  possibility  of  a 
transformation  into  carcinoma  or  sarcoma,  so  that  here  again  (see 
ji.  14)  we  must  be  doubly  certain  before  we  affirm  the  non-malig- 
nancy of  any  given  case,  and  it  is  better  to  err  on  the  side  of  radical 
interference  than  on  that  of  too  much  exjiectancy. 

Iliffi  n  nli.ll    lllaiiiiasis 

Chronic  interstitial  mastitis  may  give  rise  to  a  nodular  inliltra- 
tion  of  the  mammary  glami,  but  tliis  disajipears  under  treatment  by 
cleansing  the  iiipjile,  injection  of  alcohol  into  the  nodules,  and  sus- 
pension of  the  breast;  in  distinction  to  the  steady  growth  of  tumors. 
l>ut  there  ai'e  luany  doubtful  cases,  and  this  diagnosis  is  very  dillicult. 
Cysts  orcnr  rliiell>-  ill  the  iieiiilil lorjicu m  1  (if  the  nipjile,  from  which  a 
brownish  lluid  can  be  expressed.  When  they  appear  under  the  skin 
they  can  be  recognized  by  their  bluish,  glistening  surface. 

Galactocele  begins  develojiing  dni-ing  a  lactation  period  and  has, 
when  large,  a  special  doughy  cousistemy.  Incision  discloses  mas.ses 
of  cheesy  material. 

49 


Carcinoma  of  the  breast  is  characterized,  as  already  said  (page 
13),  by  its  hardness,  its  infiltration  into  the  tissues,  retraction  of  the 
nipple  and  dimpling  of  the  skin.  However,  a  few  cases  of  metastatic 
carcinoma  in  the  breast  {e.g.,  a  metastasis  from  a  chorioepithelioma 
observed  by  the  writer)  are  encapsulated,  movable  and  of  slow  growth 
as  a  benign  tumor.  Such  rare  occurrences  could  be  suspected  only  by 
the  knowledge  of  the  primary  growth,  and  correctly  diagnosed  only 
by  microscopical  examination. 

The  latter,  made  by  a  competent  man,  is  the  last  and  final  resort 
for  the  diagnosis  of  breast  tumors,  and  must  be  performed  in  all  un- 
certain cases.  If  the  immediate  examination  of  frozen  sections  at 
the  time  of  operation  is  conclusive  (which  unfortunately  is  not  al- 
ways the  case)  the  surgeon  has  a  safe  criterion  to  guide  his  further 
course. 

Treatment 

Early  removal  of  all  chronic  nodular  formations  in  the  breast  is 
advisable.  They  should  be  exposed  by  an  incision  radiating  from  the 
nipple  (but  avoiding  it)  and  extirpated  with  the  adjacent  mammary 
tissue.  Large  tumors  can  be  removed  subciitaneously  by  raising  the 
breast  through  a  curved  incision  at  its  lower  border  so  that,  after 
healing,  the  scar  is  hidden  under  the  breast  which  overhangs  it. 

In  very  extensive  growths,  especially  cystic  fibroadenoma  and 
multiple  cystic  disease  of  the  breast,  the  whole  gland  should  be  re- 
moved. But  it  is  not  necessary  to  remove  the  pectoral  muscles,  or 
thoroughly  clean  the  axilla,  so  that  the  unpleasant  after  effects  of 
radical  amputation  of  the  breast  (edema  of  the  arm,  interference 
with  the  function  of  the  latter)  will  not  be  so  marked. 


Fig.  38  shows  a  slightly  curved  cutaneous  horn  about  three-fifths 
of  an  inch  long,  in  an  old  countrywoman,  in  the  zygomatic  region, 
with  all  the  characteristic  features.  The  skin  at  the  base  of  the 
growth  is  scaly  and  somewhat  reddened.  The  same  figaire  also  shows 
multiple  pin  point  adenomata  of  the  sebaceous  glands. 

Cutaneous  horns  occur  more  frequently  in  old  people  (senile  kera- 
toma), and  in  those  subject  to  exposure  (sailors,  etc.).  They  develop 
on  preexisting  sebaceous  and  dermoid  cysts  and  warts,  and  are  ob- 
served on  the  eyelids,  nose,  lips,  cheeks  and  ears,  also  on  the  scalp 
and  genital  organs.  They  are  seldom  multiple.  They  generally  form 
sessile,  freely  movable,  curved  or  spiral  striTctures  which  have  an  ir- 
regular, grooved,  yellowish-brown  surface  and  a  horny  consistency. 

50 


E  kenlieimer,  Atlas 


Tab.  XXIX. 


n.iii  Comp.iny,  Ncw-^■oI■k. 


Tlieso  honi.aii  rdriii.itioiis.  wliicli  iii;iy  iitt.iin  a  lenfj;tli  of  two  inclies 
or  nioro,  are  forinctl  \>y  a  in-olil'i-ratioii  of  tlic  horny  layer  of  tlie  epi- 
derniis.  The  pai)ilhi'  are  also  k'ii,i;tlioiKHl,  wliirli  accounts  for  tlie  soft 
consistency  of  the  inner  core. 

Ihjj,  rrnliiit  Itiiiniio.ti.t  iiiitl  rrcihiiiiil 

In  young  people  iimltiple  nirxi  willi  cornification  dccin-,  l>iif  these 
have  a  wider  hase,  and  a  flatter  ami  iiniro  prickly  siufacc 

As  about  10  per  cent,  nf  ciilancniiN  Ikhiis  degenerate  iiitn  carci- 
noma (see  page  1),  excision  l)y  \\\r  knife  with  a  ring  of  healthy  skin 
is  indicated.  Eccurrence  takes  place  after  removal  l)y  simple  liga- 
ture. 

Adenoma  of  the  skin  develop.s  from  the  sebaceous  glands  or  from 
the  sweat  glands  {adenoma  sebaceum,  adenoma  sudoriparum).  Both 
conditions  are  rare:  adenoma  sebaceum  seems  fairly  frequent  in 
England. 

Adenoma  sebaceum  consists  in  small  translucent  tumors,  im- 
bedded in  the  skin :  of  pin  point  to  small  pea  size,  round,  movable, 
enca]isulated  and  circumscribed,  which  usually  occur  on  the  flush  area 
of  the  face,  often  in  women,  young  or  old,  and  is  very  often  associated 
with  telangiectases.  The  consistency  of  the  tumors  is  quite  firm. 
This  lesion  is  benign,  does  not  involve  the  lymphatics  and  does  not 
recur  after  removal.    It  is  u.sually  congenital. 

Adenoma  sudoriparum  (multiple  benign  cystic  epithelioma, 
Puscii)  is  still  rarer;  the  tumors  are  much  like  those  of  adenoma  se- 
baceum, but  generally  slightly  larger.  The  surface  is  quite  smooth 
and  glistening:  the  tumors  look  a  little  like  vesicles.  It  is  also  a  eon- 
genital  lesion.  Any  large  adenoma  of  the  skin  should  be  extirpated. 
Smaller,  pin-point  size  lesions  may  be  treated  by  the  X-rays.  This 
was  done  in  the  case  rejiresented  in  Fig.  38,  and  the  small  tnindv-; 
dis-:i))penred  to  a  great  extent.    Electi'olysis  is  also  a  suitable  met  hod. 


Fig.  39  slidws  a  horseshoe  sliapecl  endothelioma  "f  the  zygo- 
matic re,nion.  in  an  old  wouiaii.  Tlie  tumor  is  situated  in  the  skin 
and  has  grown  out  of  it.  It  is  uiovalile  over  the  sulija<'eut  tis.sues. 
The  bonlei-s  are  ret^ular  on  all  si(h's.  The  skin  over  the  tumor  is 
reddish  brown  like  sarcoma,  \-ei-y  tliin,  and  canuol  he  j-aised  IV(UU 
the  tumor.  It  shows  numerous  line  ramifying  vessels.  In  the  middle 
of  the  horseshoe  is  an  ulcer  which  resembles  a  rodent  ulcer.  There 
are  thus  points  of  resemblance  to  both  carcinoma  ami  sarcoma.    The 


soft  borders  and  consistency,  the  circumscribed  form,  and  the  ab- 
sence of  glandular  involvement,  show  the  benign  nature  of  the  tiamor. 
In  endothelioma  of  the  face  the  occuri'ence  of  small  multiple  cysts  in 
the  cutaneous  covering  is  more  common  than  ulceration. 

Excision  of  the  tumor  was  performed  and  the  defect  was  repaired 
lay  a  plastic  operation.  Microscopic  examination  showed  the  growth 
to  be  a  plexiform  hemangio-endothelioma. 

The  group  of  tumors  linked  together  under  the  name  of  endothe- 
lioma is  far  from  being  homogeneous;  its  histology  is  exceedingly 
complex  and  unsettled,  and  the  very  existence  of  a  group  of  tumors 
to  which  the  name  endothelioma  would  properly  belong  has  recently 
been  questioned. 

The  opinions  heretofore  most  generally  admitted  maj''  be  sum- 
marized as  follows : 

Endotheliomata  (Golgi)  arise  from  the  endothelium  of  the  blood- 
vessels and  lymphatics,  which,  according  to  Borst,  consists  of  speci- 
ally modified  connective-tissue  cells.  Owing  to  the  double  nature  of 
the  endothelium,  it  is  not  surprising  that  those  who  regard  endothelial 
cel-ls  as  epithelial  cells  give  the  name  of  endothelial  cancer  to  the 
tumors  arising  from  them,  while  others,  who  regard  endothelial  cells 
as  connective-tissue  cells,  call  these  tumors  endothelial  sarcoma,  plexi- 
form angiosarcoma  {Waldeyer)  and  angiosarcoma  {Kollaczeh). 

If  we  hold  with  Borst  that  endothelium  cells  are  but  connective- 
tissue  cells,  which  may  assume  all  kinds  of  modifications,  it  follows 
that  tumors  of  varied  structure  may  arise  from  the  different  varieties 
of  endothelium.  According  to  cases,  these  tumors  bear  a  resemblance 
to  fibroma,  sarcoma  or  carcinoma  (but  without  cornification).  Thus 
we  avoid  the  endless  number  of  names  given  to  these  tumors,  and 
clinically  have  only  the  term  endothelioma,  to  be  further  analyzed 
microscopically  as  hemangio-endothelioma  and  lymphangio-endotheli- 
oma.  In  these  two  great  groups  we  can  still  divide  cases  into  alveo- 
lar, plexiform  or  vascular,  according  to  their  microscopic  structure. 

Clinically,  endothelioma  may  appear  in  the  most  varied  forms  and 
be  mistaken  for  fibroma,  adenoma,  sarcoma  and  carcinoma  (more  par- 
ticularly the  first  two),  from  which  it  may  be  distinguished  only  by 
microscopical  examination. 

Endothelioma  may  arise  from  all  kinds  of  endothelium  and  is  most 
frequently  observed  in  the  skin  of  the  face,  the  mucous  membrane  of 
the  mouth  and  pharjmx,  the  bones  of  the  face  and  skull,  the  perito- 
neum, the  pia  mater  of  the  brain  and  spinal  cord,  and  the  parotid 
gland.     (See  Fig.  40.) 

52 


Bockenheimer,  Atlas. 


Fig.  40.     Endothelioma  parotidis  —  Tumor  mi.xtus. 


Rebman  Company,  New- York. 


Occurring  at  any  age,  it  forms  encapsulated,  generally  slow-grow- 
ing, comparatively  benign  tumors  which  seklom  cause  glandular  or 
organic  metastases,  but  have  a  tendency  to  local  recurrence. 

As  the  sha])e.  surface  and  consistency  of  the  tumor  may  assume 
all  possible  varieties,  the  clinical  signs  of  endothelioma  are  very  in- 
delinite.  The  sha])e  is  often  irregular,  especially  in  endothelioma 
of  the  face  (Fig.  39,  horseshoe  shape).  The  surface  may  be  smooth, 
uneven  or  uhcraled.  The  consistency  may  be  hard,  soft  or  cystic. 
Sometimes  the  tumors  are  very  vascular  and  the  epidermis  takes 
the  reddish-brown  coloration  whicli  is  seen  in  sarcoma  (Fig.  40)  at 
other  times  they  ai-c  ]ioor  in  vcssi'Is.  Although  they  are  at  first  en- 
capsulated they  nuiy  later  on  give  rise  to  a  diffuse  infiltration  of  the 
tissue  along  the  endothelial  clefts,  and  then  have  irregular  boun- 
daries. 

Trcatmoit 

Ea>l,ij  e.rcisioii  is  indicated,  as  transformation  in  ra])idly  growing 
tumors  is  possible.  In  the  ditTuse  forms,  which  represent  nialig-naut 
tumors  like  carcinoma  and  sarcoma,  extensive  operations  are  neces- 
sary. When  multiple  nodules  develop  in  the  extremities  amputation 
is  sometimes  necessary.  Metastases  in  the  lymi)hatic  glands,  which 
appear  in  the  form  of  soft  nodules,  should  also  be  removed. 


Fig.  40  shows  a  mixed  tumor  of  the  parotid  which  slowly  de- 
veloi^ed  during  three  years  in  a  woman  aged  30.  Profuse  salivation, 
and  latterly  rapid  growth  of  the  tumor,  led  the  patient  to  seek  advice. 
The  skin  is  freely  movable  over  the  tumor  and  shows  a  fine  network 
of  vessels.  The  tumor  lies  under  the  fascia  and  has  sjjread  to  the 
anterior  and  lower  region  of  the  ear.  The  surface  is  irregular;  the 
consistency  of  the  posterior  jiortion,  where  the  surface  is  uneven,  is 
hard ;  that  of  the  anterior  portion,  where  the  surface  is  smooth,  is  soft 
and  fluctuating.  The  tumor  does  not  project  into  the  buccal  cavity; 
it  is  freely  movable  over  the  subjacent  parts,  and  there  is  no  glandu- 
lar enlargement. 

The  tumor  was  extirpated  with  its  capsule,  and  tlio  facial  nerve 
avoided.  Part  of  the  parotid  gland  was  left  behind.  On  section,  carti- 
lage, cysts,  calcification,  and  iii)rous  and  sarcomatous  tissue  were 
found. 

Mixed  tumors  occur  frequently  in  the  parntid.  less  often  in  the 
other  salivary  glands.  These  mixed  tumors,  which  also  occur  in  the 
breast,  kidneys  and  testicles,  are  regarded  as  endotheliomata  (see 

5.3 


page  49)  by  some  authors,  while  others  hold  that  they  arise  from  epi- 
thelial and  connective-tissue  cells. 

On  section,  they  show  a  very  variegated  structure,  in  which  are 
found  parts  resembling  carcinoma  and  sarcoma,  mucoid  and  calcified 
tissue,  cartilage  bone,  cysts.  The  presence  of  cartilage,  which,  to  the 
feel,  is  the  most  characteristic  element,  coupled  with  the  often  slow 
growth,  is  responsible  for  the  nam«  enchondroma  often  given  these 
tumors. 

Parotid  tumor  occurs  more  often  in  young  individuals,  and  ap- 
pears as  an  encapsulated,  smooth  or  nodular  tumor,  movable  over 
subjacent  parts,  lying  imder  the  fascia,  and  covered  by  intact  non- 
adherent skin.  The  rare  tumors  which  lie  above  the  parotid  fascia 
probably  originate  in  aberrant  parotid  rudiments.  The  consistency 
of  parotid  tumors  may  be  stone  hard,  hard,  soft  or  cystic,  according 
to  their  composition,  and  may  diiTer  in  different  parts  of  the  same 
tumor.  At  first  they  increase  slowly,  but  may  suddenly  take  on  rapid 
growth,  break  through  their  capsule,  infiltrate  the  surrounding  parts 
like  malignant  tumors,  and  finally  perforate  the  skin  and  ulcerate. 
In  such  cases  there  are  glandular  and  organic  metastases. 

Tumors  arising  from  the  anterior  part  of  the  parotid  cause  swell- 
ing of  the  cheek;  those  arising  from  the  posterior  part  of  the  gland 
raise  up  the  external  ear.  Large  tumors  may  extend  toward  the 
chin,  the  nape  of  the  neck  and  the  clavicle.  In  a  few  cases,  the  growth 
bulged  exclusively  toward  the  faucial  region  (Mixter)  and  could  be 
extirpated  through  the  buccal  cavity. 

Small  tumors  cause  hardly  any  pain,  but  sometimes  salivation. 
Extensive  tumors  may  give  rise  to  pain  in  the  ear,  deafness  and  facial 
paralysis. 

Differential  Diagnosis 

The  more  common  cartilaginous  tumors  with  uneven  surface  are 
easy  to  distinguish  from  other  growths,  but  the  soft  tumors  with 
smooth  surface  may  be  mistaken  for  salivary  cysts,  cavernous  angi- 
oma, lymphangioma,  lymphadenom^a,  lipoma,  fibroma,  myxoma,  sar- 
coma and  carcinoma.  As  all  of  these  tumors  call  for  extirpation,  an 
exploratory  incision  which  will  become  the  first  step  of  a  radical  in- 
terference, is  justified  in  all  doubtful  cases. 

Treatment 

Mixed  tumors  should  be  extirpated  as  early  as  possible  on  account 
of  the  possibility  of  their  taking  on  malignant  character.  Both  be- 
nign and  malignant  recurrence  may  take  place  from  the  remains  of 

54 


Bockenheimer,  Atlas. 


Tab.  XXXI. 


r 


■T0*^- 


Rebman  Company,  New- York. 


the  capsule  after  removal  of  tumor.  The  capsule  must,  therefore, 
be  completely  removed  during  extirpation,  which,  however,  is  always 
a  very  diflicult  and  delicate  procedure  owin.ij-  to  tlie  more  tlian  inti- 
mate aiintomical  relations  between  the  parotid  tissue  and  the  facial 
nerve. 

The  latter  must  not  be  sacriliced  except  when  the  major  interest 
of  radical  removal  makes  it  imperative  (malignant  tumors).  Even 
when  care  is  taken  to  avoid  large  bvanclies  of  tlie  nerve,  when  part 
of  the  gland  is  unaffected  and  can  be  h'ft  beliiml,  facial  i)aralysis  is 
frequent  on  account  of  si  retelling  duiing  operation,  or  of  infiltration 
of  the  sheath  of  the  nei-ve  by  bluod.  |>ut  if  the  nerve  has  not  been 
divided,  jiaralysis  is  only  temporary. 

In  tumors  of  the  subnuixilhn-y  gland,  very  siniilai'  in  nature  to 
those  of  the  parotid,  the  whole  gland  should  always  be. removed.  This 
procedure  presents  no  special  difficulty  as  to  technicpie. 


Fig.  41  shows  a  so-called  "ganglion,"  that  is,  a  i)eriarticular  cyst, 
developeil  in  a  hernial  protrusion  of  the  synovial  membrane  of  a 
joint  (more  particularly  of  the  wrist  and  hand)  through  an  interstice 
l)etween  adjoining  bundles  of  fibres  of  the  capsule.  The  case  shown 
in  Fig.  41  is  in  a  ty[)ical  situation.  It  was  observed  in  a  young  girl,, 
and  was  a  recurrence  of  a  previous  forcibly  broken  cyst.  Extirpa- 
tion of  the  ganglion  resulted  in  cure.  The  unilocular  cyst  contained 
colloid  matter.  The  presence  of  septa  gave  evidence  of  an  earlier 
multilocular  structure. 

Ganglions  most  often  oceur  on  the  dorsal  surface  between  the 
extensor  carpi  radialis  and  extensor  indicis,  less  commonly  on  the 
palmar  side  near  the  flexor  car])i  radialis  (especially  in  jnanists)  :  also 
on  the  dorsum  of  the  foot  at  the  joints  of  the  cuboid  bone  and  in  the 
neighborhood  of  the  knee  joint. 

According  to  the  theory  most  connnouly  accepted,  ganglions  are 
only  retention  cysts  in  a  protrusion  of  the  synovial  cavity  which  has 
secondarily  become  isolated,  or  is  connected  with  the  articular  cavity 
only  by  a  nuire  or  less  slender  ]iedicle.  According  to  another  theory 
colloid  degenei'ation  of  the  joint  capsule  and  the  lu'i-iarticuhir  con- 
nective tissue  gives  rise  iirsl  to  multilocular,  then  unilocular  cy>ts. 
Ganglions  of  the  tendon  sheaths  develop  in  the  bmsa'  normally  ex- 
isting between  two  tendons  where  they  cross  eacli  other.  They  occur 
cliietty  in  the  shealhs  of  the  llexor  tendons  over  the  uietacai-po-iiha- 
laugeal  joints,  and  cause   neuralgic  pain   by  pressure  on  the  digital 


nerves.  They  often  occur  after  rowing  and  fencing,  i.e.,  from  trau- 
matic causes. 

Spherical  ganglions  occur  most  commonly  on  the  dorsal  aspect  of 
the  hand  in  young  women,  and  resemble  exostoses  on  account  of  their 
hardness.  They  often  cause  neuralgic  pains  and  slight  trouble  in  the 
movements  of  the  joints. 

Ganglions  are  of  slow  growth,  the  skin  is  unaltered  and  movable 
over  them;  the  surface  is  smooth  or  slightly  wrinkled.  The  con- 
sistency is  hard  in  small  ganglions,  soft  and  fluctuating  in  larger 
ones.  In  pedunculated  ganglions  there  is  slight  mobility  over  the 
joint. 

Differential  Diagnosis 

In  the  knee  joint  they  may  be  mistaken  for  affections  of  hursce;  in 
the  foot,  for  ganglions  of  the  tendon-sheaths.  Tuberculous  teno- 
synovitis is  distinguished  by  its  nodular  surface,"  its  fusiform  shape 
following  the  direction  of  the  tendon,  and  sometimes  by  the  fine  grat- 
ing sound  it  gives  on  motion  or  pressure. 

Treatment 

The  only  treatment  to  be  recommended  is  extirpation  of  the  cyst 
and  its  pedicle  imder  strict  observance  of  all  rules  of  asepsis,  for 
ganglions  often  communicate  with  the  joint,  or  are  only  separated 
from  the  latter  by  a  thin  membrane. 

The  time-honored  method  of  bursting  the  ganglion  by  violent 
pressure  of  both  thumbs  or  a  blow  with  a  wooden  hammer,  and  then 
compressing  with  a  bandage  often  leads  to  recurrence.  So  do  sub- 
cutaneous discision,  puncture,  injection  of  alcohol  or  simple  incision. 
All  these  methods  are  nowadavs  obsolete. 


Fig.  42  shows  an  acute  purulent  inflammation  of  the  prepa- 
tellar bursa.  Fig.  43  shows  a  chronic  inflammation  of  the  same 
bursa,  attended  by  the  development  of  the  cystic  formation  commonly 
called  hygroma.  The  lower  half  of  the  pretihial  bursa  is  also  in- 
volved. 

Bursitis  is  acute  or  chronic,  purulent  or  nonsuppurative. 

Acute  bursitis  supervenes  especially  after  injuries  of  the  region, 
or  after  neighboring  inflammations  (furuncles,  lymphangitis,  ery- 
sipelas). 

In  serous  bursitis  (rheumatism)  the  skin  is  unchanged.  In  puru- 
lent bursitis,  it  is  red  and  edematous  far  beyond  the  limits  of  the  in- 

56 


Bockenheimer,  Atlas, 


Tab.  XXXII. 


Fig.  43.    Hygroma  genus  multiloculare. 


Rebman  Company,  New- York. 


flamed  hurs.i.  Siiii)iiii';iti(iii  .ilsn  may  cxU'iid  l)eyon(l  those  limits  and 
cause  a  dirfiisc  plilci^iiKui.  'I'lic  iimvements  of  the  neij^hhoring  joint 
are  painful  and  limitccl  and  there  is  iiip^li  fever.  Under  the  movahle 
skin,  in  the  case  of  snperlicial  l)urs;r  {e.g.,  the  prepatelhir),  a  hemi- 
si)herieal,  tense,  sometimes  fhictuatins-,  slisjlitly  movalile  swollin,!!:  witii 
a  smootli  sni'face  can  1)0  felt,  limited  to  the  anatomical  ))osition  of  the 
hursa  (Fig.  42). 

Hygroma  is  n'ci-v  i^cncrally  an  occiiiKitniiKil  (liscasc,  liecauso  re- 
peated contusions  and  chronic  irritation  are  the  most  important  etio- 
logical factors.  Hygroma  of  the  prepatellar  hnrsa  is  well  known 
among  persons  who  have  to  work  in  the  kneeling  position  (as  was 
tlie  case  with  the  man  whose  knee  is  shown  in  Fig.  43) :  hence  the 
name  of  "hoiisemniirs  hiice."  The  "miner's  elhoir,"  hygroma  of 
the  olecranon  bursa,  and  the  rider's  hygroma,  on  the  internal  aspect 
of  the  internal  condyle  of  the  femur,  are  other  frequent  jiroofs  of  the 
same  causal  relation.  It  would  be  easy  to  multiply  examples:  there 
is  not  a  trade  requiring  constant  pressure  and  rubbing  over  a  special 
point  of  the  body  that  does  not  supply  instances  of  the  developinent  of 
bursa?  in  this  same  traumatized  point  and  of  subsequent  hygroma. 

Plygroma  may  also  develop  in  adventitious  bursa?  developed  with- 
out occupational  trauma,  for  instance,  on  the  toes  over  a  corn  or 
bunion,  or  in  any  other  point  where  the  skin  passes  over  a  prominence 
of  bone  subjected  to  pressure. 

\'illous  jiroliferations  and  rice-like  bodies  are  often  observed  in  the 
walls  of  chronic  hygroma.  When  rice-like  bodies  are  found,  the  case 
is  generally  considered  as  tuberculous. 

The  skin  covering  a  hygroma  is  movable  over  the  tumor,  but  rough 
and  thickened,  owing  to  the  rejieated  irritation.  The  hygroma  forms 
a  tumor  of  varying  size  (some  as  large  as  a  child's  head)  and 
liarfhiess  according  to  the  thickness  of  its  walls,  but  always  too  tense 
ill  glrc  real  /hut iiiilidii.  The  hygroma  is  sphei'ical  when  developed  in 
a  niiilocular,  regular  bursa;  it  is  nmltilocular  and  irregular  in  sliape 
(Fig.  43)  when  in  a  large  bursa. 

It  causes  no  ]iaiTi,  aiid  no  functional  dislurbnnce  exce]it  by  its  vol- 
ume; wlii'Ti  large,  il  liimlcrs  m(i\'cmenl.  In  tlii'  case  ol'  "miner's 
elbow,"  there  may  li(>  disaliilily  or  ueurali^ic  pain  from  pressure  on 
the  ulnar  nerve. 

DilJinnlial   JUainiosis 

The  different  forms  of  bursitis  7uay  be  mistaken  for  arthritis  of 
the  adjacent  joint,  owing  to  limitation  of  movement,  e.g.,  suV)deltoid 

57 


and  sub-trochanteric  bursitis.  The  strict  localization  of  the  affection 
to  the  anatomical  position  of  the  bursse  should  make  the  diagnosis 
easy.  Multiple  bursitis  is  chiefly  observed  in  tuberculosis,  syphilis, 
gonorrhea  and  gout,  and  inquiries  must  be  pushed  in  the  direction 
suggested. 

Treatment 

Acute  bursitis  requires  early  incision  to  stop  the  progress  of  the 
condition  and  its  extension  to  the  adjacent  structures.  Acute  serous 
bursitis  is  apt  to  undergo  spontaneous  resorption,  which  may  be  has- 
tened by  compression.  Tapping  and  injection  of  a  few  drops  of  car- 
bolic acid  or  alcohol  will,  at  times,  prove  useful. 

For  chronic  hygroma,  the  only  treatment  to  be  recommended  is 
total  extirpation,  when  feasible  (sometimes  the  cyst  is  too  large,  or 
has  too  intimate  connections  with  a  joint,  and  part  has  to  be  left  be- 
hind) ;  or,  when  total  excision  is  not  possible,  incision,  scraping  and 
sivabbing  with  carbolic  acid,  alcohol  or  tincture  of  iodine.  When 
treating  a  hygroma,  always  remember  the  possibility  of  communica- 
tion with  a  joint. 

The  bursitis  shown  in  Fig.  42  was  incised.  All  three  bursas — sub- 
cutaneous, subfascial  and  subaponeurotic  were  full  of  pus  and  in 
communication  with  each  other. 

The  hygroma  shown  in  Fig,  43  was  extirpated.  The  two  bursfe 
were  in  communication.   - 

Fig.  44  shows  a  tumor  the  size  of  a  walnut,  in  an  old  woman.  Its 
situation  in  the  isthmus  of  the  thyroid  gland  is  evidenced  by  its  ascen- 
sion during  swallowing.  Its  rounded  form  and  regTiIar  outline  and 
consistencjr  show  that  it  is  a  cyst.  The  lesion  is  therefore  a  cystic 
goiter. 

Goiter  is  endemic  in  some  countries  (Switzerland),  but  sporadic 
cases  are  fairly  frequent  everywhere.  Its  real  cause  is  unknown, 
though  many  are  the  hypotheses  that  have  been  made  on  this  point. 

Pathologically,  the  goiter  may  be  follicular,  colloid,  vascular,  cys- 
tic or  fibrous.  These  different  varieties  may  all  be  found  together 
in  the  same  tumor.  The  characteristic  feature  of  all  thyroid  tumors 
is  ascension  with  the  larynx  during  deglutition. 

The  simplest  form  of  goiter  is  follicular  hypertrophy.  The  gland 
is  slightly  enlarged  and  studded  with  small,  hard  nodules  which  may 
persist  indefinitely,  undergo  resorption,  or  more  frequently,  increase 
in  size  and  lead  to  colloid  or  cystic  degeneration. 

■       58 


<enlieimer,  Atlas. 


Tab.  XXXIII. 


CuUu'td  dccjciicralioii.  i.s  jiccuiuiiaiiieil  liy  a  lari^cr  liy[)orii'opliy  of 
the  gland  with  formatiou  of  a  liorseshoe-shajjed  tumor  containing 
several  large  nodules  of  gelatinous  cmisistoncy.  If  the  vascular  ele- 
ment predominates,  there  is  in  a(  Mi  lion  iml^atinn  .hkI  compressibility. 
If  several  smaller  colloid  nodules  coak'sce  to  loiiii  a  cyst,  tliere  results 
a  hemispherical  tumor  as  shown  in  Fig.  44,  witli  distinct  fluctuation, 
which,  however,  may  be  lacking  if  the  walls  of  the  cyst  are  sclerotic, 
thickened  or  calcilled.  If  fibrosis,  tlie  ultimate  evolution  in  some 
cases,  is  marki'd,  there  is  atrophy  and  hardening  of  the  thyroid  gland. 

The  symptoms  caused  by  a  goiter  dejjcnd  on  the  location  of  the 
tumor  and  on  its  size,  which  may  vary  within  very  wide  limits.  Even 
small  goiters  cause  marked  and  early  deformity.  Further  increase 
is  accompanied  by  pressure  on  the  veins  of  the  neck  (cyanosis  of  the 
face,  development  of  the  subcutaneous  network  of  veins). 

Pressure  on  the  trachea  causes  displacement,  stricture  and  flat- 
tening of  the  cartilaginous  rings,  causing  the  tube  to  assume  the 
shape  of  a  saber  sheath.  Sometimes,  but  not  nearly  as  often  as  as- 
sumed by  Base,  there  may  be  softening  of  the  tracheal  wall  to  such 
an  extent  that  the  latter  gives  way  after  a  violent  movement  of  the 
head.  Changes  in  the  tracheal  wall,  important  to  know  before  opera- 
tion, may  be  detected  by  the  X-rays.  Pressure  on  the  trachea  causes 
dyspnea,  especially  of  the  inspiratory  tj'pe,  stridor,  siidden  asthmatic 
attacks.    Sudden  death  has  been  sometimes  observed. 

Pressure  on  one  recurrent  nerve  is  of  little  consequence,  and  often 
unnoticed  because  unilateral  recurreutial  paralysis  is  compensated 
and  can  be  detected  only  by  laryngoscoi)ic  examination,  as  hoarse- 
ness is  not  present.  Bilateral  recnrrciitial  paralifsis  is,  on  the  con- 
trary, exceedingly  grave  (asphyxia,  pneumonia). 

Small  fil)rous  tumors  arising  in  the  midline  from  the  isthmus  of 
the  thyroid  and  those  lying  behind  the  sternum  (retrosternal  or 
"plunging"  goiter)  are  those  that  cause  the  most  troublesome  pres- 
sure symptoms. 

Diagnosis 

Diagnosis  of  goiter  is  not  i)arlicular1\'  iliHicult. 

Carcinoma  of  the  thyroid  i>  a  disease  of  elderly  and  old  people. 
It  is  a  nodnlar,  \cry  hard  ami  ra]>idly  growing  tumor  which  soon 
infiltrates  all  the  tissues  of  the  neck  and  promptly  leads  to  paralysis 
of  the  vocal  cords,  to  glandular  metastases  and  cachexia.  A  sud- 
den, rapid  growth,  in  did  iicdplc.  in  ;in  old  standing  goiter  is  always 
suggestive  of  malignancy. 

50 


Sarcoma  of  the  thyroid  is  a  rare  affection  occurring  in  young 
people.  The  infiltration  is  diffuse,  but  the  consistency  is  soft.  Sar- 
coma may  break  through  the  capsule  and  give  rise  to  severe  hemor- 
rhage. 

Syphilitic  gumma  of  the  thyroid  gland  is  probably  not  as  rare  as 
the  scarcity  of  observations  would  lead  us  to  believe,  but  the  clinical 
history  is  little  known,  and  barring  anamnesis,  a  positive  Wasser- 
mann  reaction  and  the  influence  of  specific  treatment,  there  are  no 
diagnostic  elements. 

Tuberculosis  of  the  thyroid  gland  may  also  assume  a  nodular 
form,  not  unlike  follicular  goiter,  but  the  cases  well  studied  are  not 
numerous  enough  to  enable  one  to  give  a  clear  description. 

Aberrant  goiters,  when  connected  with  the  thyroid  by  a  palpable 
pedicle,  are  easily  recog-nized;  But  when  free,  they  may  be  mistaken 
for  lymphoma,  adenitis,  sebaceous  or  dermoid  cysts  or  malignant 
tumors. 

Retrosternal  goiter  is  a  mediastinal  tumor,  and  as  such  may  be 
mistaken  for  any  of  the  other  kinds,  particularly  aortic  aneurysm. 

Exophthalmic  goiter  {Graves'  disease)  is  characterized  by 
symptoms  of  hyperthyroidism  (tremor,  palpitations,  highly  nervous 
condition,  etc.)  associated  with  bulging  of  the  eyes  and  hypertrophy 
(always  moderate  in  pure  cases)  of  the  thyroid  gland.  The  train 
of  symptoms  is  sufficiently  typical  to  allow  the  diagnosis  to  be  made: 
but  symptoms  of  hyperthyroidism  may  sometimes  appear  in  cases 
of  long-standing  goiters. 

Treatment 

Incipient  follicular  hypertrophy  can  be  happily  influenced  by  io- 
dine preparations  or  thyroid  extract  (administered  with  caution,  lest 
we  produce  symptoms  of  hyperthyroidism). 

In  localized  lesions,  cysts  or  nodes,  the  remainder  of  the  gland 
being  sound,  enucleation  is  indicated. 

In  more  diffuse  forms,  in  colloid  degeneration  particularly,  par- 
tial thyroidectomy  by  the  Mayo  suhca,pstdar  technique  is  the  best 
operation.  Total  thyroidectomy  is  not  physiologically  permissible, 
as  it  is  followed  by  post-operative  myxoedema,  akin  to  congenital 
myxcedema,  sometimes  associated  with  cretinism,  observed  in  coun- 
tries where  goiter  is  endemic.  An  entire  lobe  is  generally  left,  that 
is,  the  more  affected  lobe  and  the  isthmus  are  taken  away. 

The  subcapsular  technique  wards  off  the  danger  of  post-opera- 
tive tetany  due  to  the  removal  of  all  parathyroid  glandules  situated 

60 


Bockenheimer,  Atlas. 


Tab.  XXXIV. 


Fig.  45.     Papilloma  cutis  inflainmatorium. 


Rebmaii  Company,  New-York. 


licliiiid  tlif  lliyroiil  lolics,  and  tlic  aiiatdinii-al  (lisposilioii  of  wliicli  is 
vai-ial)l('.  Should  all  iiaratliyroids  1)0  iiiadvertt-iitly  rt'iiioved,  totally 
may  i>c  prevented  by  imniodiate  iinpUiiitdtioii  into  tlio  al)dominnl  wall 
of  one  or  two  of  the  excised  parathyroids;  or  it  may  be  cured  l)y  sul)- 
cutaneous  injectiou  of  an  extract  of  paratliyroids  or  by  the  use  of 
calcium  lactate  {Beehc,  McCdlliiiii). 

Transplantation  of  thyroid  frafpnciils  has  also  boon  attomptod 
for  the  cure  of  myxcedema. 

In  Graves'  disease,  when  the  hygienic  treatment  fails,  o])orative 
measures  are  indicated.  In  not  too  severe  cases  ligation  of  the  thy- 
roid arteries  (up  to  three)  often  brings  about  marked  relief  and 
lessens  the  hyperthyroidism.  It  can  be  done  quickly  under  local 
anesthesia  and  in  severe  cases  may  be  a  i)reliminary  step,  preceding 
by  a  few  days  partial  thyroiilectomy,  which  is  then  indicated.  There 
are  no  cases  in  which  post-operative  toxemia  can  be  so  hyperacute. 
Therefore  the  operation  must  be  done  under  local  anesthesia,  as 
quickly  and  as  gently  as  possible  so  as  not  to  squeeze  thyroid  secre- 
tion into  the  circulation.  The  results  are  excellent  when  the  danger- 
bus  post-operative  period  can  safely  be  tided  over,  and  no  class  of 
patients  are  moi-e  grateful  to  the  surgeon  who  has  cured  them 
\Crile).  Therefore  it  is  important  not  to  delay  surgical  interference 
too  long,  and  not  to  dally  with  ineffectual  internal  remedies  until  the 
patient  is  in  a  hopeless  condition. 


Fig.  45  shows  a  so-called  "papilloma"  of  the  skin.  It  is  a  small 
tumor  freely  movable  over  the  underlying  parts,  of  rather  soft  con- 
sistency, and  covered  with  warty  projections.  It  has  been  frequently 
cauterized:  hence  the  abrasion  of  the  surface,  and  the  inflammation 
of  the  surrounding  skin.  The  surface  is  covered  with  a  yellowish, 
fetid  secretion,  and  between  the  villous  projections  are  deep  depres- 
sions caused  by  ulceration,  so  that  the  appearance  in  some  places  is 
almost  that  of  carcinoma,  but  the  borders  are  not  hard. 

In  the  past,  the  name  "papilloma"  has  been  used  to  designate 
various  growths  of  the  skin,  consisting  of  hypertrophied  papillae 
covered  with  epithelium  (warts,  nsvi,  condylomata).  It  was  even 
claimed  that  true  papilloma,  as  distinguished  from  paiiillomatous 
formations,  was  a  special  type  of  fibro-opitholial  tumor. 

Nowadays  the  tmn  papilloma  of  tlu'  skin  is  ol)solete;  at  least 
in  so  far  as  the  skin  and  cxtcinal  niiicuus  nicnibranos  (see  iiapilloma 
of  Iho  longno.  Figs.  6  and  7)  :n'c  cnnrci  ihmI.  it   is  adniiltod  that  the 

(il 


so-called  "papillomata"  are  not  tumors  in  the  usual  sense  of  the 
word,  but  simply  papillary  and  epithelial  hypertrophies  developed 
under  the  influence  of  repeated  irritations,  chiefly  of  an  infectious 
nature,  in  regions  that  are  warm  and  moist;  hence  the  frequencj^  of 
these  lesions  around  the  mucocutaneous  junctures  of  the  genitals 
(venereal  warts). 

Similar  growths  may  be  observed  on  internal  mucous  membranes 
(larynx,  intestines,  bladder).  On  account  of  their  vascularity,  they 
bleed  very  easily,  and  hemorrhage  is  one  of  their  chief  symptoms. 
In  the  bladder,  villous  tumors  sometimes  degenerate  into  carcinoma 
or  recur  as  carcinoma  after  excision. 

Treatment 

The  best  treatment  of  papilloma  is  excision.  Papillomatous 
tumors  of  internal  organs,  especially  the  bladder,  are  very  well  re- 
moved by  sparking  with  high  frequency  currents  (Beer,  Keyes  Jr.). 
External  "papillomata"  may  be  destroyed  with  the  galvanocautery 
or  strong  caustics.    Mild  cauterizations  only  irritate  the  lesion. 


Figs.  46,  47  and  48  show  three  cases  of  dermoid  cysts. 

Fig.  46  shows  a  dermoid  of  the  forehead,  where  it  is  often 
observed,  either  above  the  root  of  the  nose,  in  the  inner  angle  of  the 
ej'-e,  or  laterally  near  the  glabella  (fissural  dermoid  cyst).  The  skin 
is  movable  over  the  tumor,  which  was  observed  in  early  youth,  and 
shows  a  small  white  scar  left  by  a  former  insufficient  operation.  The 
surface  of  the  tumor  is  smooth  and  hemispherical.  At  the  periphery 
there  are  raised  bony  walls.  The  tumor  slowly  attained  its  present 
size  after  the  former  operation  and  then  remained  stationary.  There 
is  no  diminution  on  pressure  over  the  tumor.  It  is  of  doughy  con- 
sistency and  but  slightly  movable  over  the  subjacent  bone. 

I 

Fig.  47  shows  a  dermoid  of  the  prepuce,  situated  symmetrically 
on  both  sides  of  the  raphe,  and  present  since  birth.  The  skiii  is  so 
thin  that  the  contents  can  be  seen  through  it.  The  tumor  has  caused 
phimosis  and  balanitis. 

Fig.  48  shows  a  dermoid  of  the  neck  in  the  position  of  the  second 
branchial  arch.  Symmetrical  dermoids  in  the  middle  line  may  occur 
above  or  below  the  larynx.  Dermoids  of  the  floor  of  the  mouth  may 
cause  bulging  of  the  submental  region.  The  tumor  has  the  size  of 
a  hen's  Qgg,  a  smooth  surface,  a  doughy,  semi-fluctuating  consistency. 

62 


Bockenliciiiicr,  Atlas. 


Tab.  .\XX' 


Fig.  46.     Dermoid  —  Recidiv. 


Fjo-.  47.     ncnnnid        Phimosis. 


Rebnian  Company,  New- York. 


Bockenheiraer,  Atlas. 


Tab.  XXXVI. 


Fig.  48.     Dermoid  —  Cystis. 


Kebman  Company,  New-York. 


It  is  not  adlierent  to  sul)jaceiit  parts  nor  to  tlie  unaltered  skin.  It 
dated  hack  to  int'aiicy:  it  lirst  jirew  slowly,  later  l)ecaiiie  stationary, 
and  caused  no  inconvenience  apart  from  the  disfigurenient. 

True  dermoid  cysts  are  formed  by  invagination  of  the  epihiast 
only,  while  compound  dei-moid  cysts  {Tenituntu,  Fig.  146)  include  all 
tliree  embryonic  layei's. 

Dermoid  cysts  occur  (uily  wlirii-.  in  I'mlnynnic  lilc,  there  were 
folds,  furrows  or  recesses,  or  in  i)laces  where  origans  are  developed 
by  invagination  of  the  epiblast.  The  latter  mode  explains  dermoids 
in  the  vertebra!  canal,  cranial,  thoracic  and  abdominal  cavities,  retro- 
peritoneal tissue  and  kidneys.  The  former  mode  of  development 
accounts  for  tlie  (issnral  dermoid  cysts  in  the  regions  of  the  head,  of 
the  face  (Fig.  46),  in  the  neck,  at  the  umbilicus  and  in  the  coccygeal 
region. 

Dermoid  cysts  of  the  testicles  and  ovaries,  on  account  of  their 
complicated  structure,  are  not  ]inrc  dermoids. 

Pure  dermoids  are  unilocular  or  nuiltilocular  cysts,  the  external 
walls  of  which  consist  of  connective  tissue,  and  are  connected  with 
the  surrounding  tissues  while  the  internal  surface  resembles  skin 
(hence  the  term  dermoid),  and  presents  papilla^,  squamous  epithelium 
and  hair.  Those  dermoids  which  contain  bone,  cartilage  and  teeth  are 
formed  at  a  very  early  embryonic  period,  before  differentiation  has 
taken  place. 

The  contents  of  the  cyst  consist  of  a  yellowish-white,  caseous,  odor- 
less, fatty  mass,  mixed  with  numerous  hairs,  the  appearance  of  which 
varies  according  to  the  situation  of  the  dermoid  (in  the  region  of  the 
eye,  eyelashes,  etc.).  The  contents  are  rarely  serous  or  hemorrhagic. 
In  the  cutaneous  or  subcutaneous  tissue  the  cysts  form  spherical 
or  hemisi)herical  tumors  with  a  smooth  surface  and  tallowy  con- 
sistency. They  are  covered  liy  intact  skin,  and  are  often  attached  to 
the  bones.  The  superficial  dermoids  usually  occur  in  youth.  They 
are  slow-growing  and  ])ainless,  and  about  the  size  of  a  walnut.  Some- 
times fistuhie  form,  from  which  hairs  protrude. 

Diiujnosis 

The  dia.gnosis  of  superficial  dermoids  is  easy  to  estal)lish  by  the 
above  signs. 

But,  according  to  the  region  of  the  body  in  which  they  are  situated, 
even  superficial  dermoids  may  be  mistaken  for  other  conditions,  sncli 
as  sebaceous  cysis,  for  instance,  but  the  contents  of  the  latter  are 
yellow  and  foul  smelling. 

Lipomata  are  not  congenital  and  are  generally  lobiilnted. 

f)3 


A  cyst  in  the  location  of  that  shown  in  Fig.  46  might  be  diagnosed 
encephalocele;  but  the  latter  attains  a  much  larger  size  and  diminishes 
on  i^ressure  (see  Fig.  142  and  page   2;J1). 

Also  in  the  same  case,  owing  to  the  scar  of  the  previous  operation, 
an  epidermic  inclusion  cyst  might  be  thought  of ;  however,  the  latter 
is  not  congenital,  develops  only  after  a  trauma,  and,  on  microscopical 
examination,  its  walls  contain  only  squamous  epithelium  without  any 
sebaceous  or  sweat  glands. 

A  dermoid  cyst  of  the  neck  (Fig.  48)  may  be  mistaken  for  a 
tubercidous  adenitis,  a  branchiogeiious  cyst,  a  thyro-glossal  cyst  (see 
Fig.  57,  median  fistula  of  the  neck).  None  of  these  conditions,  how- 
ever, has  the  doughy  consistency  of  a  dermoid  cyst. 

Dermoids  of  the  umbilicus,  on  account  of  their  special  hardness, 
may  be  mistaken  for  malignant  tumors,  but  they  are  of  slow  growth 
and  circumscribed.  Dermoids  of  the  abdominal  walls  are  often  mis- 
taken for  sarcoma  and  fibroma,  but  the  latter  increase  in  size  while 
dermoids  remain  stationary. 

Deeply  situated  dermoids  of  the  various  cavities  and  organs, 
which  often  are  noticed  only  by  accident,  cannot  as  a  rule  be  dis- 
tinguished from  other  tumors. 

Treatment 

Extirpation  of  the  whole  cyst  is  necessary,  as  recurrence  takes 
place  if  any  part  is  left  behind.  Commencing  carcinoma  has  been 
observed  in  the  inner  surface  of  the  cyst  wall  (Wolff). 

Extirpation  was  carried  out  in  the  three  cases  represented. 


Fig.  49  shows  a  fibroma  of  the  sheath  of  the  flexor  tendon  of 

the  finger,  the  yellowish-white  surface  of  which  shows  through  the 
skin.  The  skin  is  slightly  movable  over  the  hard  nodular  tumor.  The 
tumor  itself  is  movable  over  the  subjacent  structures,  and  remains 
unaltered  in  position  on  moving  the  finger,  which  fact  shows  its  inde- 
pendence from  the  tendon  itself.  Fibromata  of  tendon  sheaths  are 
rare  on  the  whole,  and  are  due  to  traumatic  causes. 

After  injuries  and  stretching  of  tendons  similar  growths  occur, 
sometimes  multiple;  they  are  due  to  proliferation  of  the  cellular 
tissue.  In  Dupuytren's  contraction  (Fig.  60)  nodules  also  develop 
in  the  palmar  aponeurosis,  which  somewhat  resemble  fibro^nata. 

Thickenings  which  occur  in  tendons  and  tendon  sheaths,  and  lock 
tire  movements  of  the  fingers  in  certain  positions,  are  not  true 
fibromata. 

64 


BuckL-iiliL-iiuL-r,  Atlas. 


Tab.  XXXVII 


Rcbinan  Company,  New- York. 


Fil)i-oina  is  ;i  licnimi  '■iiiiiicctivc-fissiii'  tmiior,  cunsistiiifx  of  con- 
uective-tissiic  rdls,  HliiilLii-.  inlcr  cclluljir  substiinf-e  and  a  variable 
amount  of  bluud  vessels  and  l\  inplialics.  Wlien  tlie  matrix  is  hard 
and  abundant,  with  slight  develojiment  of  spindle-cells,  the  fibroma 
is  hard,  wliilo  soft  fibi-oiiia  is  foi-inocl  by  s])nn,i>y  tissue  witli  minifrous 
blood-vessels. 

Those  fibromata  which  consist  of  librous  connective  tissue  with 
few  nuclei  are  also  termed  fJesmoids,  esiiecially  when  they  occur  in 
the  fascia  of  tlie  abdominal  walls,  while  the  term  fibrosarcoma  is 
aiijjlied  to  tumors  which  consist  of  irregularly  arranged  spindle  cells 
with  little  intercellular  substance,  and  sliow  deuciiei-ative  changes 
and  an  absence  of  mature  tissue. 

'J'ransitional  forms  from  fibroma  to  fibrosarcoma  and  sarcoma  are 
especiallj'  observed  in  the  tumors  occurring  in  fascia.  Mixed  foi-ms 
are  often  found,  such  as  fibro-liporaa,  fibro-myoraa,  fibro-adenoraa 
and  fibro-myxoma.    Cystic  formation  is  also  seen  in  fibromata. 

Fibromata  occur  in  all  situations  where  fibrillar  connective  tissue 
is  present — in  the  cutaneous  and  subcnlaneous  tissue  (back  and 
thigh),  in  intermuscular,  intertendinous  (Fig.  49),  submucous  and 
subserous  tissue  (alimentary  canal,  uterus,  larynx).  They  may  also 
develop  in  fascifB  and  aponeuroses,  nerve  sheaths  and  pei-iosteum 
{uaso-phani)igeal  tumors,  Fig.  25,  and  epulis,  Fig,  35),  and  also 
within  the  internal  organs.  Filn-eids  of  the  uterus  are  the  most  fre- 
quent of  all. 

Fibromata  form  circumscribed  tumors  of  fii'm  consistency  and 
smooth  surface,  often  encapsulated,  slow-growing,  sessile  or  peduncu- 
lated (tibrolipoma  pendulum,  Fig.  52).  Pedunculated  submucous 
fibromata  often  occur  in  the  larynx  in  singers.  Fibroid  tumors  may 
occur  at  any  age;  they  are  seldom  congenital.  After  metaplastic 
changes   (ossification)   they  may  become  hard. 

In  the  skin  and  sul)cutaneous  tissue  they  have  a  yellowish-white 
surface  (Fig.  49).  On  section  they  show  stratification  and  a  glisten- 
ing appearance  like  tendon  tissue. 

Diffrrnificil  ilUifiiiosix   niiil    trral iiuiil 

Superficial  hard  liliroiiiata  ol'  llie  skin  and  siilicutaiieoiis  tissue  are 
easily  recognized  by  their  form,  consistence,  clear  demarcation  and 
solitary  appearance.  It  is  oidy  transitional  forms  between  fibro- 
sarcoma and  sarcoma  that  ])resent  any  difficulty.  T)ee]i  fibromata 
which  oflen  attain  a  large  size  (c.p..  in  the  abdominal  cavity)  are 
recognized  by  llieir  iiddular  siirfai-e.  hardness  and  ciicapsulatiou. 

65 


Treatment 

Treatment  is  excision  of  the  tnmor  with  its  capsule.  For  the 
removal  of  deep  fibromata  extensive  operations  are  necessary.  Some- 
times they  are  so  firmly  attached  to  the  neighboring  tissues  or  organs 
that  a  portion  of  the  latter  must  be  removed  with  them.  In  other 
cases,  they  can  be  shelled  out  without  difficulty  (enucleation  of  uterine 
fibroids). 


Fig.  50  shows  a  case,  observed  in  a  young  man,  of  multiple 
chondroma  of  the  fingers,  which  had  been  present  since  childhood. 
The  nodular  tumors  are  situated  in  the  phalanges  and  metacarpal 
bones,  and  have  caused  thinning  and  reddening  of  the  skin  by  pres- 
sure. The  X-rays  showed  the  origin  to  be  in  the  medullary  cavity. 
The  tumors  on  tlie  first,  second  and  fourth  fingers  were  incised  and 
scraped.  The  little  finger  was  removed  with  its  metacarpal  bone,  on 
account  of  the  multiplicity  of  the  tumors. 

Although  cartilaginous  tumors  are  pathologically  divided  into  two 
groups:  (1)  ecchondroma,  or  hyperplastic  proliferation  from  pre- 
existing cartilage,  which  only  occurs  in  places  where  cartilage  is 
usuall}^  present;  (2)  lieteroplastic  cartilaginous  growths,  or  enchon- 
droma,  which  occur  in  places  where  cartilage  is  not  normal])^  pres- 
ent, these  two  foi'ms  are  often  impossible  to  distinguish  clinically. 
We  therefore  include  both  forms  under  the  name  of  chondroma. 

The  tumors  either  consist  of  the  different  forms  of  cartilage,  or 
else  they  are  mixed  (cliondro-myxoma,  chondro -lipoma,  or  chondro- 
sarcoma). Cystic  degeneration  may  also  occur  in  chondroma,  and 
by  liquefaction  of  cartilaginous  tumors  large  cysts  may  form  in  the 
long  bones.  True  chondroma  may  occur  in  the  soft  parts  from 
aberrant  pieces  of  cartilage  in  the  neighborhood  salivary  glands, 
neck,  ear,  lungs,  trachea,  mammary  gland. 

The  mixed  tumors  occurring  in  the  testicles  and  salivary  glands, 
which  develop  cartilaginous  tissue  through  metaplasia,  are  not  true 
chondroma. 

Congenital  chondroma  and  chondroma  develoi^ing  in  infancy, 
according  to  Virchow,  are  due  to  disturbances  in  the  development  of 
bone  during  the  period  of  growth,  and  arise  from  islands  of  cartilage 
left  in  the  diaphysis.  Rickets  appear  to  play  a  certain  role  in  this 
connection  owing  to  the  irregnilar  ossification  of  the  epiphyseal  car- 
tilages. In  some  cases  there  appears  to  be  a  hereditary  tendency  ta 
the  formation  of  chondroma. 

66 


Bockenheimer,  Atlas. 


Tab.  XXXVIII. 


Fie.  51.     Hamorrhoides  et  Fibromata  ani. 


Rebman  Company,  New- York. 


Tine  (•Itoiirlroma.  or  ciiclinniliotn;!,  (l('Vf'ln])s  from  tlio  poriosteum 
or  inciliilla,  most  coiiii liy  in  tlic  |ili;il;iiif>-('.s  ;iiul  mt't;ic;iri);il  or  meta- 
tarsal bones;  it  is  usually  multiple.  Cases  of  isolated  cliondroma  also 
occur  in  the  u]ii)pr  oud  of  the  humerus,  the  lower  end  of  the  radius, 
the  head  of  the  lilii.i,  flic  iidxic  hones  and  the  scapula,  often  com- 
bined willi  cartila.uinuus  exostoses  (ossified  ecehondromata  Avith  a 
cartilaginous  covering). 

Chondroma  forms  slow-growing,  hard,  nodular,  circumscribed 
tumors,  whicli  may  cause  pressure  atrophy  of  neighboring  parts 
(Fig.  50)-  Alulliplc  tumors,  especially  in  the  hands,  cause  consider- 
alilc  (Icfoi'inity  li\  disturbance  of  growth  (shortening  and  twisting). 
Spontaneous  fractures  may  occur  from  destruction  of  the  cortex,  in 
tumors  growing  from  the  medullary  cavity. 

The  softer  forms  of  chondroma,  less  comnimi  than  the  hard,  must 
be  regarded  as  malignant,  because  they  take  on  an  infiltrating 
growth,  extend  to  the  veins  and  give  rise  to  metastases.  {Chondro- 
sarcoma.) 

Diffcniiiiiil  didgiwsis 

Central  medullary  chondroma  has  to  be  dia.gnosed  from  osteo- 
myelitic  abscesses  and  from  central  sarcoma.  The  former,  on  X-ray 
examination,  show  thickening  of  the  pei'iosteuni ;  the  latter  can  often 
only  be  distinguished  by  operation,  as  the  X-ray  appearances  are  very 
similar  in  chondroma  and  sarcoma  (when  the  chondroma  is  single). 
Large  chondromata  of  the  head  of  the  tibia  or  ujiper  end  of  the 
humei'us,  and  generally  speaking  peripheral  chondromata  are  easily 
recogTiized  by  their  nodular  surface  and  typical  hard  consistency. 
Multiple  hard  tumors  are  always  suggestive  of  chondroma. 

Treatment 

Any  isolated  chondroma  should  always  be  extirjiated,  as  it  may 
develop  into  sarcoma.  IMultiple  tumors  (case  of  Fig.  50)  may  be 
incised  and  scraped.  If  rapidly  growing  recurrence  takes  place, 
resection  or  amputation  must  be  performed. 


Fig.  51  shows  around  the  anus  yellowish  nodular  hemorrhoids, 

which,  owing  to  the  concomitant  moist  eczema  and  rciieatcd  ulceration 
and  inflanunatory  changes,  have  undergone  iibrous  changes  and 
somewhat  resemble  fibromata.  Tu  one  place  there  is  a  typical  bluish, 
glistening  hemorrhoidal  iiodiilc 

67 


Hemorrhoids,  the  most  common  surgical  condition  of  the  anus, 
are  external  or  internal,  according  to  their  location. 

External  hemorrhoids  are  those  developed  from  the  inferior 
hemorrhoidal  plexus.  Constipation  and  pelvic  congestion  are  two 
favoring  factors  in  their  development.  They  form  bluish,  com- 
pressible, nodular,  sessile  or  pedunculated  growths  covered  by  thin 
skin  and  situated  around  the  anal  orifice.  When  turgid  and  iniifimed 
they  cause  much  itching,  pain  and  tenesmus,  while  the  nodules  bleed 
easily  and  thrombophlebitis  is  frequent.  The  latter  and  the  moist 
eczema  bring  about  the  changes  shown  in  Fig.  51. 

Multiple  internal  hemorrhoids  of  the  lower  part  of  the  rectum 
bleed  easily  without  being  inflamed  and  are  often  accomj^anied  by  a 
slight  mucous  prolapse. 

Diagnosis 

When  situated  high  up  in  the  rectum,  a  proctoscopic  examination 
is  necessary.  For  ordinary  cases,  digital  examination  is  generally 
sufficient  for  the  diagnosis. 

Condylomata  acuminata,  frequent  in  the  anal  region,  might  be 
mistaken  for  hemorrhoids  only  on  superficial  examination.  The 
cockscomb-like  vegetations  are  too  characteristic.  The  same  may  be 
said  of  condylomata  lata. 

Genuine  anal  fibroma  is  rare,  solitary  and  pedunculated. 

Carcinoma  of  the  papillomatous  type  is  recognized  by  its  early 
ulceration  with  hard  borders  and  irregular  outline,  and  surface  bleed- 
ing to  the  slightest  contact.  In  all  cases  of  hemorrhoids,  a  digital 
exploration  should  be  made  for  carcinoma. 

The  treatment  of  hemorrhoids  consists  in  cleanliness,  antiphlo- 
gistic measures  during  the  periods  of  inflammation,  and  removal 
of  the  nodules  if  they  are  too  troublesome,  either  by  the  clamp  and 
cautery  method  (applied  in  the  case  of  Fig.  51)  or  by  a  bloody  opera- 
tion if  there  is  a  complete  ring  of  sessile  tumors.  Anal  dilatation 
is  the  first  step  in  all  operations  for  hemorrhoids. 


Figs.  52  to  54,  inclusive,  show  three  types  of  lipoma. 


G8 


Bockenheimer,  Atlas. 


Tab.  XXXIX. 


Fig.  52.     Fibrolipoma  subcutaneum  pendulum. 


Rebman  Company,  New-York. 


Fig.  52  shows  a  pendulous  fibro-lipoma  in  a  middle-aged  woman. 
The  skin  is  somewhat  reddened,  but  non-adlierent.  The  tumor  is 
smooth,  moderately  hard  in  consistency  and  moval)le  over  the  f:i~i'i,i. 
Its  base  is  broad,  on  account  of  its  small  size. 

Fig.  53  shows  a  sub-cutaneous  lipoma  Hie  size  of  the  fist  in  a 
common  situation  in  a  middle-aged  woman.  The  puckering  of  the 
skin  is  clearly  seen.  These  puckcrings  (white  spots  in  the  figure)  are 
also  found  in  the  breast,  and  are  due  to  processes  of  the  lipoma  ex- 
tending into  the  latter. 

Fig.  54  shows  symmetrical  lipomata  in  the  region  of  both 
parotids,  in  the  upper  eyelids,  and  in  various  parts  of  the  neck  (both 
sides  of  submaxillary  region  and  sublingual  region)  in  an  old 
man.  The  painless  tumors  had  not  increased  in  size  for  some  years. 
Their  lobular  surface  and  their  consistency  distinguish  these  solid 
tumors  from  symmetrical  cystic  formations  in  the  salivai'y  glands, 
which  cause  similar  swellings  in  the  face  and  neck.  (See  about  lymph- 
angioma and  Miliulicz'  disease,  page  2.36.)  The  disease  is  distin- 
guished from  sim^jle  adiposis  by  consisting  of  multiple,  separate, 
encapsulated  tumors.  There  were  no  other  lipomata  in  other 
parts  (in  distinction  to  cases  in  which  lipomata  occur  over  the  whole 
body). 

Lipomata  are  tumors  formed  of  fatty  tissue,  and  have,  therefore, 
the  yellowish-white  color,  soft  consistency,  and  lobular  structure  of 
fatty  tissue.  The  individual  fat  lobules  are  separated  by  more  or 
less  strongly  developed  connective-tissue  septa,  and  the  whole  tumor 
is  demarcated  from  the  surrounding  tissues  bj^  a  thin  capsule.  Lipo- 
mata are  of  soft,  often  pseudo-fluctuating  consistency;  in  rare  cases 
they  are  harder,  because  they  contain  more  connective  tissue. 

They  are  slow-growing,  globular  tumors,  which  sometimes  attain 
an  enormous  size,  and  are  usually  supplied  by  a  single  vessel  at  their 
base.  They  are  generally  sessile.  In  large  tumors  the  skin  is  often 
drawn  so  as  to  form  a  broad  pedicle.  Narrow  pedunculated  lipomata 
(Fig.  52)  are  rare. 

Lipomata  are  essentially  benign  tumors,  which  neither  recur,  nor 
give  metastases,  nor  undergo  malignant  changes. 

Besides  the  fat,  which  differs  from  ordinary  fatty  tissue  only  in 
that  the  globules  are  sliglitly  larger,  there  may  be  other  constituents, 
hence  the  varieties  fibro-lipoma,  myxo-lipoma,  angio-lipoma,  chondro- 

G9 


lipoma.     Cystic  degeneration  may  give  rise  to  so-called  oil-cysts  in 
the  interior  of  lipomata. 

The  etiology  of  lipoma  is  unknown.  That  it  is  a  true  tumor  is 
shown  by  its  persisting  in  severe  emaciation.  Thus  are  multiple 
lipomata  distinguished  as  a  nosological  entity  from  obesity,  though, 
clinically,  it  may  be  difficult  in  some  cases  to  know  which  of  the  two 
conditions  we  are  dealing  with. 

That  repeated  irritations  may  act  as  a  predisposing  cause  is 
demonstrated  by  the  development  of  lipomata  on  the  back  of  carriers 
and  on  the  forehead  of  persons  who  wear  hard  hats.  Pregnancy  may 
give  a  sudden  impetus  to  the  growth  of  stationary  lipomata. 

Developmental  and  trophic  disturbances  undoubtedly  play  an  im- 
portant part  in  the  production  of  multiple  lipomata,  which  are  usually 
symmetrical  (Fig.  54). 

Symmetrical  lipomatosis  has  been  described  as  a  separate  morbid 
process.  Multiple  lipomata  may  be  connected  with  nerves  or  with 
lymphatic,  glands,  which  sometimes  have  been  found  within  them. 
The  connections  with  nerves  explain  why  those  multiple  lipomata 
are  often  painful  [Dercum  has  described  a  variety  under  the  name  of 
adiposis  dolorosa). 

Congenital  lipoma  is  found  especially  in  spina  bifida  of  the  myelo- 
cystocele variety  (usually  myxolipoma,  Fig.  144). 

Lipomata  are  most  often  found  in  the  subcutaneous  tissue  (Figs. 
52,  53  and  54),  where  they  appear  as  soft,  encapsulated  tumors  with 
a  lobulated  surface,  covered  by  non-adherent  skin.  The  skin  over  the 
tumor  becomes  dimpled  when  i^inched  up,  owing  to  its  connection  with 
the  tumor  by  connective  tissue  (Fig.  53).  The  seats  of  predilection 
for  subcutaneous  lipomata  are  the  back,  nape  of  the  neck  (fatty  neck), 
axilla,  shoulder,  upper  arm,  thigh,  buttocks  and  scrotum.  In  the 
limbs  lipomata  become  less  and  less  frequent  as  the  region  becomes 
more  distant  from  the  attachment  to  the  trunk. 

Subfascial  lipomata  are  much  less  common.  They  may  occur 
under  the  fascia  of  the  forehead  (where  they  may  be  mistaken  for 
dermoids,  see  page  63)  and  under  the  palmar  fascia.  Intermuscular 
lipomata  occur  behind  the  pectoralis  major  and  in  the  tongaie.  In 
the  knee  joint  arborescent  lipoma  occurs,  which  has  the  typical  struc- 
ture of  fatty  tissue,  and  is  connected  by  some  authors  with  tubercu- 
losis of  the  knee,  healed  or  of  very  low  virulence.  Lipomata  may  also 
arise  from  the  submucous  and  subserous  tissue  (gut  and  larynx) ; 
subperitoneal  lipomata  may  give  rise  to  hernia  through  the  linea 
alba.     Subserous  lipomata  also  sometimes  appear  in  the  inguinal 

70 


Bnrkenlu'iiiier,  Atlas. 


V'\g.  53.    Upiima  (.iillii>uiii  subcutaiicuni. 


Rcbm.m  Company,  Ne\v-\'ork. 


Bockenheimer,  Atlas. 


Tab.  XLI. 


Fig.  54.     Lipomata  subcutanea  symmetrica. 


Rebman  Company,  New-York. 


and  foiiioral  caiiiils;  in  the  oiiK'iitum  and  inosontery ;  in  tlic  retro- 
peritoneal tissne,  and  in  tiie  ,n-iandiiiar  orf^an.s  (l)reast  and  kidney). 

Ail  lij)oniata,  especially  suhcntaneous,  suhfascial  and  inter- 
muscular, have  a  tendency  to  send  processes  into  the  surrounding 
parts. 

The  cliarncU'rislic  rc.-iluics  of  li|i(iiiia.  fidiii  the  staiHlpoiiit  of 
diagnosis,  are  the  t>uft,  ptniudo-jlmtnatuui  consiatciuti  and  the  lobu- 
lar surface  with  i)uckering  of  the  skin. 

Fihromala  are  harder;  sebaceous  cysts  are  round,  smooth  and 
more  tense;  cijst.s  and  hyrjromata  are  perfectly  smooth;  dcnnoids 
have  a  special  doughy  consistency.  Adenitis  has  small,  hard  nodes, 
unless  already  suppurative  and  does  not  much  resemble  lipoma. 

The  fatty  accumulations  seen  after  long  suppurations,  for  in- 
stance in  the  perirenal  capsule  (lipomatous  perinephritis)  are  not 
true  lipomata.    Nor  is  diffuse  lipomatosis  (obesity). 

Trcntiiunt 

The  treatment  of  lipoma  is  cxtirindion  of  the  tumor  and  of  all  its 
processes.  This  was  applied  to  the  three  cases  represented  in  the 
illustrations:  several  sittings  were  necessary  for  the  case  represented 
in  Fig.  54. 

In  cases  of  lipoma  of  the  limbs  (such  as  that  of  Fig.  53)  c-are 
must  be  taken,  because,  despite  its  encapsulation,  the  tumor  may 
have  sent  processes  in  all  directions,  eusheathing  the  big  blood  ves- 
sels and  nerves,  which  it  is  important  not  to  wound. 

Adiposity  of  the  abdominal  walls  has  recently  been  treated  sur- 
gically. Kelly  advocates  removal  of  large  masses  of  fat  by  wedge- 
shaped  excisions  before  laparotomies.  This  facilitates  the  work  of 
the  surgeon,  insures  better  repair  of  the  abdominal  wall  and  lightens 
the  patient. 


71 


MISCELLANEOUS  LESIONS 

Figs.  55-83 


A.— Scars— Fistulae— Figs.  55-59 

B.— Deformities  Due  to  Contractions  of  Muscles  or 
to  Fractures— Figs.  60-66 

C.-Naevi-Figs.  67-69 

D.— Lesions  of    the    Lymphatic    and  Vascular   Sys- 
tems—Figs. 70-83 


Bockenheimer,  Atlas. 


Fig.  55.    Granulationes  et  Transplantationes. 


Rebman  Company,  New- York. 


SCARS    FISTULAE 

Fig.  55  shnws  ;i  granulating  wound  li'l'l  !'>'  Hh'  extirpation  of 
the  rig-ht  breast,  and  three  epidermic  grafts  that  have  been  trans- 
planted thereon.  After  extirjiatioii  of  the  lireast,  an  attempt  sliould 
always  be  made  to  close  the  wound  by  sutures,  but  these  sliould  not 
be  tied  too  tightly,  especially  in  the  center  of  the  wmmd,  where  there 
is  much  tension,  as  they  arc  liaMe  to  tear  tliiiniiili  tiie  tissues  and 
cause  sloughing.  Fig.  55  shows  the  i-eddi.sii-l)rown  holes  of  the 
sutures,  which  have  led  to  partial  closure  of  the  wound  in  the  middle. 
The  remainder  of  the  wound  can  be  left  to  heal  by  granulation,  and 
TJiierscli's  grafts  may  be  applied. 

A  wound  is  ready  for  epidermic  grafts  when  it  is  covered  with 
red,  vigorously  sprout'uig  granulations.  When  the  granulations  are 
still  yellowish  (as  on  the  axillary  side  in  Fig.  55),  it  is  still  too  early. 
Balsam  of  Peru,  either  pure  or  mixed  with  oil,  is  a  very  good  di-essing 
to  promote  granulation. 

When  the  whole  surface  of  the  wound  is  covered  with  red,  ex- 
uberant granulations,  these  are  scraped  off  with  a  sharp  spoon,  and 
the  bleeding  surface  compressed  with  hot  compresses  soaked  in  saline 
solution  until  all  blood  oozing  has  been  absolutely  checked:  this  is 
essential  to  success,  as  oozing  would  raise  the  grafts  from  the  surface 
of  the  granulations;  the  largest  possible  epidermic  grafts  are  then 
applied,  each  one  overlap])ing  the  preceding,  and  covered  with  sterile 
rubber  tissue  soaked  in  saline  solution  [no  iDitiseptics  in  the  whole 
process  of  skin  grafting). 

Scarlet  red  salve  (5-8%)  is  very  efficient  to  hasten  the  epidermi- 
zation  of  granulating  surfaces  of  all  kinds  (ulcers,  partially  success- 
ful grafting  operations). 


Fig.  56  shows  a  fistula  due  to  iiisiifjicifiif  tlrdiinit/c  of  a  kidney. 

As  a  result  of  incision  of  a  ])arane])liritic  abscess,  a  tistula  has 
remained,  which,  in  spite  of  drainage,  ]iackingand  repeated  scrapings, 
has  not  healed.  The  surrounding  skin  is  inflamed  and  edematous. 
The  granulations  at  the  o]>ening  of  the  fistula  are  unhealthy,  dirty- 
hrown  and  pui'ulent.  Shreds  of  tissue  with  a  I'etid  odor  are  dis- 
charged from  the  fistula. 

75 


Such  an  appearance  of  the  fistula  and  its  surroundings  is  typical 
of  all  cases  where  the  external  opening  is  too  small,  so  that  an 
abscess  in  connection  with  it  is  not  sufficiently  drained,  or  where 
necrosed  pieces  of  tissue  in  the  deeper  parts  are  cast  off  and  act  as 
foreigTi  bodies  {e.g.  bony  sequestra  in  coxitis,  etc.  Figs.  95  and  96). 
Similar  fistulse,  with  an  offensive  sanious  discharge,  sometimes  result 
from  tampons,  drains,  or  instruments  being  left  behind  after  opera- 
tions.   Hence  veiy  simple  and  important  rules  of  caution. 

In  pyogenic  lesions  which  have  been  insufficiently  incised,  the  pres- 
ence of  unhealthy,  purulent  granulations  shows  that  the  pus  has  not 
a  free  outlet,  or  that  the  lesion  is  extending.  '^Vhen  a  local  pyogenic 
lesion  gives  rise  to  general  pyaemia  the  wound  shows  similar  changes, 
but  the  granulations,  besides  having  a  dirty  yellow  appearance,  are 
quite  dry. 

Treatment 

.Treatment  must  be  directed  to  the  cause  of  the  fistula.  The  latter 
should  be  laid  open  freelj^,  and  foreign  bodies  or  pieces  of  necrosed 
bone  removed,  after  which  healing  will  take  place. 

Such  cases  are  not  suitable  for  the  Beck  bismuth  paste  method 
(see  page  192). 

In  the  case  represented  in  Fig.  56,  the  kidney  was  found  to  be 
almost  completely  destroyed  by  suppuration.  Healing  quickly  took 
place  after  removal  of  the  kidney. 


Fig.  57  shows  a  median  fistula  of  tlie  neck  in  a  girl  aged  19. 
The  fistula  first  appeared  at  the  age  of  15,  and  was  treated  by  injection 
and  incision,  without  any  result.  A  drop  of  secretion  is  seen  at  the 
orifice  of  the  fistula.  Radiating  cicatrices  are  also  visible.  The  fistu- 
lous track  could  be  felt  as  a  cord  as  far  as  the  hyoid  bone,  but  its 
further  course  could  not  be  made  oiit  by  injections  of  fluids.  The 
foramen  cfecum  was  deep.  After  an  incision  around  the  opening  of 
the  fistula  together  with  the  scar  tissue,  the  track  was  dissected  out. 
The  center  of  the  hyoid  bone,  through  which  the  track  penetrated, 
was  removed,  so  as  to  push  the  extirpation  up  to  the  base  of  the 
tongTie.  Microscopic  examination  showed  squamous  epithelium  in 
the  lower  part  of  the  fistula  and  ciliated,  cylindrical  epithelium  in 
the  upper  part. 

Fistulce  of  the  neck  are  median  or  lateral.  They  may  be  complete; 
blind  internal  or  blind,  external. 

Those  we  are  considering  now  all  result  from  an  arrest  in  the 

76 


I'.nckciilu'iiiipr,  Atlas. 


Tab.  Xl.lll. 


Fig.  56.     Fistula  c.\  corpoix-  alieiio. 


Kcbiiian  Company,  New-York. 


Bockcnheimer,  Atlas. 


Tab.  XI  lY. 


bJ3 


Rebman  Company,  New- York. 


development  of  tlie  cervical  region,  anrl,  therefore,  are  oil  congcuital; 
but  some  are  complete  at  the  time  of  birth,  wliilo  others  (as  was  tlie 
case  in  the  jiatient  of  Fig.  57)  hecome  complete  oiih/  hij  the  secondary 
opening  to  the  skin  of  a  1)1  ind  internal  fistuhi.  The  outer  opening  of 
fistula?  of  the  first  variety  always  corresponds  in  position  to  a  point 
where  during  development  there  ivas  a  transitory  orifice:  the  outer 
opening  of  fistula?  that  liave  hecome  secondarily  complete  does  not 
necessarily,  and  in  fact,  in  most  cases,  does  not,  correspond  to  such 
a  point. 

Median  /isliila  of  the  neck  is  due  to  the  persistency  of  the  thyro- 
glossal  duct,  which  in  embryonic  life  leads  from  the  foramen  crecum 
at  the  back  of  the  toniQ:ue  to  the  middle  lobe  of  the  thyroid  gland. 
In  most  cases;  when  complete,  it  belongs  to  the  class  of  fistuhp  that 
have  become  secondarily  complete,  which  fact  explains  wjiy  they  are 
not  noticed  before  a  certain  age. 

Lateral  fistidce  of  the  neck  were  formerly  attributed  to  imperfect 
closure  of  the  second  branchial  cleft,  when  the  existence  of  genuine 
clefts  was  admitted:  now  that  we  know  that  there  are  no  real  clefts, 
but  simply  thinnings  between  the  thickened  branchial  arches,  lateral 
fistula?  are  ascribed  to  anomalies  in  the  evolution  of  the  sinus  prce- 
cervicalis. 

Heredity  is  an  important  factor,  found  in  25%  of  the  cases. 

Median  fistula?  o])en  in  the  midline  between  the  hyoid  bone  and  the 
sternum :  those  opening  low  have  been  considered  as  tracheal  fistuljp, 
but  there  is  not  a  single  well-authenticated  case  to  prove  the  exist- 
ence of  a  tracheal  communication.  There  are  no  median  supra-hyoid 
fistulfe,  and  embryology  shows  that  there  can  be  none. 

Lateral  fistula?  generally  open  along  the  inner  liorder  of  the  sterno- 
cleido-mastoid  muscle,  usually  about  an  inch  above  the  sterno- 
clavicular joint,  and  more  frequently  on  the  right  side.  Bilaterality 
is  fairly  frequent  (22%). 

The  outer  orifice  is  generally  button  shaped,  partly  cutaneous, 
partly  mucous  (sometimes  purely  cutaneous  and  difficult  to  see). 
Sometimes  its  lips  are  glued  together  by  secretion;  sometimes  a  free 
drop  of  secretion  exudes  from  it  (Fig.  57).  Tf  there  is  much  secre- 
tion the  skin  very  likely  is  eczenuitous. 

The  tract  itself  may  be  felt  by  palpation  as  a  hard,  round  cord, 
as  thick  as  a  quill  pen,  directed  upward  and  inward  toward  the  greater 
comu  of  the  hyoid  bone  in  case  of  lateral  fistula;  straight  upward 
toward  the  body  of  the  hyoid  bone  in  case  of  median  fistula.  In  the 
latter  case,  the  tract  passes  behind  or  through  the  hyoid  bone  and 

77 


ends  at  the  foramen  ccectwi  of  the  tongue.  The  tract  of  lateral 
fistula3  passes  below  the  facial  nerve,  before  the  glosso-pliaryngeal 
nerve  and  stylo-hyoid  ligament,  between  the  external  and  internal 
carotid  arteries  (that  is,  between  the  vessels  and  nerves  of  the  second 
and  third  branchial  arches).  The  upper  part  of  the  tract  is  some- 
times, if  not  always,  innervated  by  the  glosso-pharyngeal  nerve. 

The  internal  orifice  of  lateral  fistiilfe  is  found  in  a  constant  position 
in  the  tonsillar  region. 

The  direction  of  the  tract  may  be  further  ascertained  by  probing : 
this,  however,  is  generally  disagreeable  and  painful  to  the  patient, 
and  the  probe  can  hardly  ever  be  passed  above  the  level  of  the  hyoid 
bone;  which  fact  does  not  prove  that  we  are  dealing  with  a  blind 
external  fistula,  but  that  there  are  kinks  in  that  portion  of  the  tract, 
because  if  we  inject  milk  or  hydrogen  peroxide  stained  with  methylene 
blue  {Lynch's  method)  or  sapid  solutions,  we  can  often  demonstrate 
the  existence  of  the  internal  orifice. 

Narrow  fistulse  cause  little  trouble  to  the  patient,  but  in  wide, 
lateral  fistulae  accumulation  of  food  may  cause  inflammation  and 
abscess.  Carcinoma  may  arise  from  fistute  and  cysts  of  the  neck; 
it  is  called  branchiogenous,  as  it  is  derived  from  the  epithelium  of  the 
branchial  clefts. 

In  most  cases,  the  history  of  the  case,  the  appearance  of  the  open- 
ing and  the  anatomical  relations  of  the  tract  are  so  striking  that 
the  diagnosis  is  made  without  any  hesitation  whatever.  Fistulae 
arising  from  tuberculous  or  inflammatory  processes  differ  both  in 
their  external  appearance. and  in  the  course  of  the  fistulous  track. 
In  doubtful  cases  microscopic  examination  may  be  made,  which  will 
show  the  epithelial  lining  absolutely  characteristic  of  a  congenital 
tract. 

Treatment 

Injections  with  the  object  of  causing  obliteration  of  the  fistula 
are  absolutely  useless,  and  so  is  incision  and  scraping.  The  only 
rational  treatment  is  total  extirpation  of  the  fistulous  tract  through 
a  long  incision,  bearing  in  mind  the  anatomy  of  the  region  and  the 
very  important  connections  of  the  upper  part.  In  lateral  fistula  it  is 
best  to  remove  the  internal  orifice  together  with  the  tonsil.  In  median 
fistula,  it  is  sometimes  necessary  to  remove  the  middle  part  of  the 
hyoid  bone,  in  order  to  follow  the  track  to  the  foramen  caecum.  Ee- 
currence  is  unavoidable  if  the  smallest  part  of  the  fistulous  track  is 
left  behind.  Microscopic  examination  of  both  median  and  lateral 
fistulae   shows   squamous   epithelium   in   distal   sections,   cylindrical 

78 


Bockenheimer,  Atlas. 


Tab.  XLV. 


X 


Rebman  Company,  New- York. 


epithelium  in  ])roxiiii;il  sections.    The  presence  of  lymphoid  tissue  in 
tlie  wall  of  tlie  listula  is  cliaracteristie. 


Figs.  58  .111(1  59  icpicsciit  two  fasos  of  tiic  iiyp('rtro|)hic  lesion 
of  scars  known  as  keloid. 

Fig.  58  shows  a  kcldid  which  arose  on  a  vaccination  scar,  in  a 
young  girl,  and  recurred  extensively  after  extirpation.  It  appears 
as  a  large  flat  growth  with  radiating  processes;  smaller  nodules  are 
scattered  in  the  neighlidilKMMl. 

Fig,  59  shows  a  liig  noduhir  keloid  developed,  in  a  woman  of 
twenty,  in  the  scai'  of  a  laparotomy.  Each  suture  hole  has  hecome 
the  seat  of  a  nodule.  In  the  lower  part  are  seen  hard,  cauliflower-like 
nodules,  freely  movahle  and  covered  with  epidermis. 

Keloids,  the  etiology  of  which  is  still  little  known,  are  character- 
ized by  the  formation  of  homogeneous,  fibrous  nodes  in  cicatrices; 
which  nodes  consist  of  hypertrophic  scar  tissue  with  thickened  blood- 
vessels. The  chief  part  of  the  growth  consists  of  dense,  hyaline,  often 
interlacing  bundles  of  connective  tissue,  while  cells  and  elastic  fibers 
are  few  in  number.  The  papillary  bodies  are  unchanged,  but  lying 
under  them  are  nodules  or  lamelhT,  more  or  less  rich  in  cells.  In 
the  lamellar  form  (Fig,  58)  there  are  radial  processes  at  the  periph- 
ery which  are  often  prolonged  as  fine  processes  into  the  skin. 

A  l-eloid  is  a  painless  tumor  of  hard  consistency,  with  a  smooth, 
glistening  surface,  of  reddish  (Fig.  58)  or  yellowish  white  color 
(Fig.  59).  It  is  situated  in  the  skin,  at  the  site  of  a  former  scar, 
and  movable  over  the  underlying  structures.  After  it  has  reached  a 
certain  size,  it  remains  stationary. 

Barring  their  unsightly  appearance,  keloids  cause  no  incon- 
venience. They  are  absolutely  benign  lesions;  cancerous  degenera- 
tion is  seen  only  after  ulceration.  Only  if  the  keloid  is  very  large, 
and  from  its  situation  exjiosed  to  repeated  pressure  and  irritation, 
does  pain  sometimes  occur. 

Keloids  are  more  common  in  young  women.  Scars  of  burns,  ulcers 
and  vaccination  are  more  liable  to  undergo  keloidal  evolution.  The 
role  of  infection  is  not  definitely  established.  There  seems  to  be  a 
local  or  general  predisposition  in  the  individual  affected.  Some 
races  (negroes  and  other  dark  races)  have  a  special  tendency  to 
keloid  formation.  Certain  jiails  nf  the  body  are  more  affected  than 
others:  shoulders,  face,  abdomen,  ear. 

;9 


Diagnosis 

The  appearance  is  typical  and  the  diagnosis  simple.  Mei*ely 
hypertrophied  scars,  snch  as  are  seen  after  large  infected  wounds, 
and  wounds  that  have  been  drained  for  a  long  time,  are  not  real 
keloids:  they  are  usually  very  tender  and  nearly  always  flatten  out 
in  the  course  of  a  few  years.  But  sometimes  it  is  difficult — and 
maybe  the  question  has  but  an  academic  interest — to  say  where  scar 
hypertrophy  stops  and  where  keloid  formation  begins. 

Treatment 

It  is  best  to  avoid  operations,  as  cauterization  and  scraping  simply 
increase  the  keloid,  and  extirpation,  with  or  without  plastic  repair  of 
the  defect,  is  almost  uniformly  followed  by  a  recurrence  often  larger 
than  the  first  lesion.  (This  happened  in  the  case  of  Fig.  59-)  Long 
continued  compression,  especially  of  young  scars  exhibiting  a  ten- 
dency to  keloidal  hypertrophy,  has  a  certain  prophylactic  value. 
Electrolysis  or  injections  of  a  10%  solution  of  fibrolysin  (thiosi- 
namin)  sometimes  cause  improvement.  This  latter  method  was 
applied  to  the  case  represented  in  Fig.  59  and  a  partial  disintegration 
was  obtained;  but  later  on  recurrence  took  place.  ' 

Bier  claims  good  results  from  passive  hyperemia,  and  Kromayer 
excellent  results  from  the  use  of  the  quartz  lamp  in  keloids. 

X-rays,  particularly  with  the  single  dose  method  {Mackee)  are 
very  efficient. 


80 


Bockenheimer,  Atlas. 


Tab.  XLVI. 


Fig.  60.   Contractura  aponeurosis  palmaris  (Dupuytren). 


Rebman  Company,  New- York. 


DEFORMITIES  DUE  TO 

CONTRACTIONS  OF  MUSCLES  OR  TO 

FRACTURES 

Figs.  60  l<>  63,  iiielusive,  .show  acquired  deformities  of  the 
hand,  ilnc  to  coiit raction  (or  bettei'  retiactioii)  of  various  aiiatoiiiieal 
organs  (Figs.  60,  61,  63)  or  to  paraUfsis  of  muscles  (Fig.  62)  due 
to  nerve  injury. 

Fig.  60  shows  a  ease  of  Ditpui/ticii's  contraction  of  the  palmar 

aponeurosis  in  a  man  of  50.  As  is  usually  the  case,  the  fourth  and 
fifth  liiii;ers  are  more  })articu]arly  affected.  The  little  finger  is  mark- 
edly tiexed  and  only  tlie  last  phalanx  can  1)e  freely  extended.  The 
first  phalanx  of  the  fourth  finger  is  immobilized  in  flexion,  and  the 
second  begins  also  to  feel  the  effects  of  the  fibrous  retraction.  There 
is  a  very  slight  incipient  involvement  of  the  third  finger.  Neverthe- 
less, the  condition,  which  had  existed  for  several  years,  caused  so 
little  trouble  that  operation  was  refused. 

Dupuytren's  contraction  (or,  better,  reiractiou)  is  a  clironic 
shrinking  of  the  palmar  aponeurosis,  i.e.,  the  triangular  fibrous  struc- 
ture that  continues  the  palmaris  longus  muscle,  spreads  over  the  palm 
and  sends  processes  to  the  in-oximal  phalanges  of  all  the  fingers,  and 
is  also  connected  with  the  skin: 

At  first,  nodules  develop  in  the  ajioneurosis  and  skin.  Later  these 
nodules  become  cord-like  thickenings,  which  are  found  not  only  in 
the  ijalm,  but  even  more  commonly  on  the  second,  third,  fourth  and 
fifth  fingers.  Contraction  of  the  cords  gives  rise  to  an  abnormal 
position  of  the  fingers,  immobilization  in  flexed  position  of  the  first 
and  second  phalanges,  while  the  terminal  jihalanx  remains  movable. 

The  thumb  generally  is  unaffected;  the  contraction  is  often  sym- 
metrical. It  ])rogresses  slowly,  so  that  after  some  years  the  finger 
is  completely  doul)led  on  itself  into  the  palm  and  cannot  be  extended. 
There  is  generally  some  power  of  extension  left  in  the  middle  and 
terminal  ])halanges,  l)ut  as  motion  is  painful,  it  is  avoided  by  the 
patient.  The  nature  of  Ditpiii/freii's  contraction  is  unknown.  It  occurs 
almost  exclusively  in  men,  and  hence  a  traumatic  influence  was 
admitted  by  Dupui/trrii.  At  any  rate  it  is  often  found  in  men  in  whom 
the  palm  of  the.  hand  is  exposed   to  continued  pressure   (i^ost-ofKce 

81 


clerks,  from  stamping,  liunters  and  gun-bearers,  carpenters,  etc.). 
The  influence  of  trauma  is  not  accepted  by  all :  nor  is  tbat  of  gout. 
A  trophic  nervous  origin  is  the  hypothesis  most  in  favor  now,  because 
the  contraction  is  often  symmetrical  and  equally  developed  on  both 
sides,  and  it  sometimes  coexists  with  conditions  manifestly  of 
nervous  origin  (e.g.,  Recklinghausen's  disease,  for  which  see  Figs. 
67,  68,  69). 

Fig.  61  shows  a  hard,  slightly  movable  scar,  extending  from  the 
palmar  aspect  of  the  last  joint  of  the  middle  finger  to  the  center  of 
the  palm:  this  scar  resiilts  from  an  incision  made  for  suppuration 
of  the  tendon  sheath  (see  Fig.  93)-  The  flexor  tendon  is  destroyed, 
the  finger  is  half  flexed  and  stiff,  without  any  power  of  motion.  Both 
the  retraction  of  the  scar  and  the  destruction  of  the  tendon  contribute 
to  the  faulty  position  of  the  finger. 

Fig.  62  shows  the  "claw  hand"  attitude  observed  in  injuries  of 
the  ulnar  nerve.  In  this  case,  the  cause  was  a  blow  on  the  ulnar 
side  of  the  wrist-joint,  which,  perhaps,  directly  contused  the  ulnar 
nerve,  and,  in  addition,  caused  a  hemarthrosis  of  the  joint  which 
pressed  on  the  same  nerve. 

When  a  nerve  supplying  part  of  the  muscles  of  a  given  anatomical 
region  is  injured,  these  muscles  are  paralyzed,  and  their  antagonists 
immediately  become  preponderant,  and  produce  in  the  region  affected 
(this  is  particularly  plain  in  the  limbs)  a  deformity,  always  the  same 
for  the  same  nerve;  thus  the  typical  deformity  of  ulnar  "claw  hand" 
(Fig.  62)  is  due  to  the  paralysis  of  the  interossei  muscles,  whose 
function  is  to  flex  the  first  phalanges :  consequently  in  ulnar  ' '  claw 
hand,"  we  find  the  first  phalanges  of  the  fourth  and  fifth  fingers 
hyper  extended,  while  the  second  and  third  are  flexed.  The  other 
fingers  are  not  in  claw  position,  although  their  interossei  are 
paralyzed,  because  their  lumbricales  (supplied  by  the  median  nei've) 
are  still  active. 

In  the  case  of  Fig.  62,  there  was  slight  swelling  on  the  back  of 
the  wrist  joint,  chiefly  on  the  ulnar  side.  Fluctuation  was  jsresent. 
The  sign  of  "snowball  crunching"  indicated  the  presence  of  hemar- 
throsis. Motion  in  the  joint  was  limited  and  painful;  it  was  in  slight 
flexion  (the  natural  position  of  the  wrist  joint  in  case  of  intra- 
articular effusion),  but  could  easily  be  extended. 

Fig.  63  shows  a  very  important  type  of  retraction  of  the  flexor 
muscles  of  the  forearm,  that  consecutive  to  too  prolonged  ischemia 

83 


Horkpiilu'i'incr,  Atlas. 


Tab.  XLVII. 


Rebiiian  Company,  New-N'ork. 


Bockenheimer,  Atlas. 


Tab.  XLVIII. 


U 


Rebman  Company,  New- York. 


of  the  same  muscles.  Tlie  practical  importance  of  this  condition  lies 
in  the  fact  that  it  maj''  he  foreseen  and  foretold  in  some  cases  where 
it  is  hardly  avoidahle,  and  is  avoidahle,  in  a  great  majority  of  in- 
stances, throni^h  the  ohservance  of  simple  rules  of  caution;  while, 
once  it  is  established,  it  is  hardly  curable.  It  can  only  be  partly 
impi-oved  hy  surgical  interference  and  patient  after-treatment. 

This  post-ischemic  retraction  was  first  described  by  Volkmann 
under  the  name  of  ischemic  iiaralysis;  it  was  later  studied  by  Lexer 
and  other  German  authors.  Of  late  years,  American  cases  have  be- 
come quite  frequent.  Thomas  has  well  studied  the  implication  of 
nerves  in  this  condition,  and  American  surgeons  {Freeman,  Hunting- 
ton, Poivers)  have  been  conspicuous  in  the  development  of  surgical 
methods  of  treatment. 

These  ischemic  contractures  are  myogenous  and  appear  when 
the  blood  supply  of  the  muscle  has  been  cut  off  for  too  long  a  time: 
this  induces  a  special  degeneration  of  the  muscle  fibers,  which  is 
followed  hy  sclerosis  and  retraction.  Muscular  tissue  stands  ischemia 
less  well  than  the  skin,  hecause  the  arteries  of  muscles  are  terminal. 

The  causes  of  muscular  ischemia  are  manifold,  but  are  met  only 
in  traumata  of  the  limbs.  It  may  be  an  injury  to  the  main  artery, 
a  complete  laceration  with  hematoma,  or  simply  an  abrasion  of  the 
intima  in  one  point  followed  by  thrombosis  and  obliteration  of  the 
artery,  or  too  tight  a  constriction  hy  a  tourniquet,  or  long  exposxire 
to  cold;  but  by  far  the  most  frequent  cause,  the  one  that  has  most 
practical  importance,  and  the  only  one  known  to  tl\e  authors  who  first 
described  ischemic  contracture,  is  the  application  of  too  tight  a 
bandage  around  a  fractured  limb. 

Fractures  of  tlie  upper  limb,  and  particularly  of  the  lower  end 
of  the  humerus,  are  those  after  which  ischemic  retraction  has  been 
most  often  seen.  Next  come  fractures  of  the  bones  of  the  forearm. 
Out  of  about  200  published  cases  only  one  pertains  to  the  lower  limb ; 
and  strange  to  say  it  is  the  original  case  from  which  Volkmann  indi- 
vidualized the  type  of  ischemic  "paralysis."  The  predominance  in 
the  upper  limb  is  explained  by  the  lesser  bulk  of  the  muscles  in  that 
region,  and  the  frequency  with  which  the  flexors  of  the  fingers  are 
aflfected  is  quite  naturally  explained  by  the  fiat  surface  of  the  forearm 
and  the  rigid  frame  constituted  by  the  two  bones  of  the  forearm  on 
which  the  flexors  are  directly  applied. 

The  more  common  occurrence  of  ischemic  contracture  in  younger 
individuals  is  due  to  the  greater  comjiressibility  of  their  muscles  and 
vessels.     In  oi'der  to  produce  contracture,  the  ischemia  must  be 

83 


marked  enotigh  to  cause  irretrievable  lesions,  but  not  sufficient 
to  cause  gangrene.  The  latter  condition  is  wkat  happens  in  older 
persons  (whose  blood  vessels  are  sclerotic),  either  as  a  result  of  strong 
pressure,  or  of  obliterative  thrombosis  after  slight  pressure.  Un- 
fortunately, it  seems  much  easier  to  obtain  the  necessary  clegTee  for 
ischemic  contracture  unwillingly  under  a  bandage  applied  for  a  frac- 
ture than  to  gauge  it  accurately  in  experimental  work.  Up  to  the 
present  time,  ischemic  retraction,  fairly  frequent  clinically,  has  not 
been  reproduced  experimentally. 

A  few  hours  after  the  application  of  a  bandage  around  a  fractured 
limb,  the  patient  begins  to  feel  great  pains  and  numbness  of  the 
fingers.  These  become  blue,  swollen,  incapable  of  active  motion,  wliile 
passive  motion  is  painful.  The  lingers  are  flexed.  If  the  bandage  is 
then  removed,  the  skin  appears  white,  while  the  muscles  feel  as  hard 
as  board  and  are  incapable  of  motion  (hence  the  appellation  "paral- 
ysis" given  at  first).  If  the  lesions  are  not  yet  too  marked,  recovery 
may  take  place.  But  if  the  bandage  has  been  left  too  long,  the  muscles 
become  the  seat  of  a  very  painful  swelling,  rapidly  developing  soon 
after  it  is  removed;  the  fibers  are  dead  and  later  are  replaced  by 
fibrous  tissue,  which  forms  hard  lumps  in  the  muscular  body,  and 
progressive  retraction  sets  in.  The  skin  of  the  fingers  gradually 
becomes  yellowish-white  like  parchment.  The  swelling  of  the  fingers 
is  followed  by  shrinking.  First  of  all  the  fingers,  then  the  metacarpal 
bones,  and  finally  the  wrist  become  fixed  in  a  position  of  flexion.  The 
fingers  are  eventually  so  strongly  flexed  that  the  hand  becomes  use- 
less. The  movements  of  the  wrist  are  also  very  limited,  and  the 
muscles  of  the  forearm -become  atrophied  and  are  covered  by  pale 
skin.  Sensory  disorders  may  occur  from  ]Dressure  of  the  shrunken 
muscles  on  the  nerves,  and  the  implication  of  nerve  trunks  in  the 
sclerotic  masses  is  always  marked  in  severe  cases.  But  this  nerve 
involvement,  although  important  and  calling  for  a  particular  treat- 
ment in  many  cases,  is  always  secondary  in  Volkmann's  contracture. 

The  disease  has  no  tendency  whatever  to  spontaneous  improve- 
ment. Only  an  energetic  and  patient  treatment  can  give  hopes  of  a 
partial  cure. 

Diagnosis  of  deformities  due  to  muscular  action  in  the  upper  limis 

Each  one  of  the  types  shown  is  sufficiently  characteristic  to  avoid 
mistakes. 

Dupuytren's  contraction  is  seen  in  middle  aged  or  elderly  people, 
develops  sloivly  and  gradually,  and  there  are  palpable  nodes  and 

84 


ihickenings  in  the  p.-ilinnr  .ipnupurosis.  Fihiomafa  or  rj/sts  of  the 
tendon  sheatlis  (see  Fig.  49)  are  easily  dilTerentiated  from  tliese 
tliicl<enin,i>:s,  l)ecause  they  are  j^enerally  single,  well  limited,  and  round 
in  shai^e,  while  the  process  in  Dii/Jitifticii'N  contraction  is  diffuse. 

Cicatricial  contractions  .nc  .ilways  easily  diajj^iosed,  owinj?  to 
the  history  of  I  lie  disease  and  liie  presence  of  an  always  very  visible 
scar.  The  only  point  is  to  determine  how  much  the  scar  is  at  fault, 
and  how  much  the  tendon. 

A)ikylosis  of  the  finijer  joints,  such  as  is  ol)serve<l  in  fjoitfi/  indi- 
viduals (see  Fig.  141)  are  reeoiniized  hy  the  antecedent  history. 
Moreover,  the  joints  alone  are  involved. 

Volkmann's  ischemic  contraction  is  seen  in  ifoioig  individuals, 
after  a  tiaiima,  ami  jil'tcr  the  apiilication  of  a  tight  bandage.  The 
clinical  succession  of  phenomena  is  so  typical  that  the  diagnosis  can 
be  made  at  once,  if  only  one  thinks  of  it.  A  veiy  important  point, 
however,  and  one  absolutely  essential  to  a  judicious  treatment,  is 
determining  exactly  the  respective  shares  of  the  muscle  degeneration 
and  of  the  secondary  implication  of  nerves. 

Deformities  of  neurogenous  origimwe  usually  typical  enough  to 
be  easily  recognized.  The  dillicult  point  is  to  ascertain  the  cause. 
The  condition  may  be  due  to  a  central  lesion  (hemiple.gia.  Little's 
disease,  poliomyelitis),  and  an  examination  of  the  whole  nervous 
system  is  often  necessaiy  to  settle  the  diagnosis.  However,  in  a 
general  way,  we  may  say  that  a  myogenous  lesion  is  fixed  and 
wichangeahle  while  central  contracture  slightlg  varies  from  dag  to 
dag  and  disappears  under  general  anesthesia. 

Again,  the  condition  may  be  due  to  local  lesions  along  the  course 
of  the  nerve.  Among  the  latter,  we  shall  only  mention  a  few: 
(1)  callus  of  fractures  of  the  clavicle  pressing  on  the  brachial 
plexus;  (2)  supernumerary  cervical  ribs,  well  stndied  in  America 
{Keen,  Shernum),  and  the  ]iossil)ility  of  which  must  always  be  borne 
in  mind  in  ulnar  "'claw  hand."  and  iTi  writer's  cramp;  (3)  old  and 
recurrent  dislocations  of  the  shoulder  joint  with  radicular  lesions 
of  the  biadiial  plenxus;  (4)  habitual  forward  dislocation  of  the 
ulnar  nerve  over  the  tip  of  the  rpitroclilen  {C'>hh).  X-ray  exam- 
ination in  these  cases  is  invalual)le;  it  ought  to  be  performed  in  all 
cases  of  ])ressure  symptoms  on  the  nerves  of  limbs. 

Trail niriit  of  i)iii.<i<-iilnr  and  /ibrniix  retractions 

Tliere  is  no  etfective  mechanical  and  massage  treatment  suscep- 
tible of  stoiii)ing  tlie  i^rogress  of  Dupugtren  's  contraction.    In  severe 


cases,  KocJier  advises  excising  all  the  affected  parts  of  the  palmar 
aponeurosis  and  of  the  neighboring  skin  when  it  is  involved ;  the  loss 
of  substance  is  repaired  with  skin  flaps.  Massage  must  be  begun 
shortly  after  the  operation.  Injections  of  fibrolysin  give  only  doubt- 
ful results. 

The  conservative  treatment  of  cicatricial  contractions  such  as 
that  represented  in  Fig.  61,  where  both  the  skin  and  the  tendon  are 
involved,  is  not  very  successful,  because  of  the  impossibility  of  making 
a  new  serous  sheath  around  the  tendon.  After  excision  of  the  scar, 
contracture  occurs  in  the  new  cicatrix,  in  spite  of  extension  of  the 
finger,  lengthening  of  the  tendon,  transplantation  of  tendon  or  catgut, 
or  plastic  operations.  If  the  patient  is  incapacitated  from  work  by 
the  contraction,  exarticulation  of  the  finger  is  the  best  policy. 

In  cases  of  contractions  limited  to  the  skin,  such  as  those  after 
cuts  and  burns,  keloids,  superficial  suppuration,  etc.,  the  prog-nosis 
is  much  better.  Excision  of  the  scar,  extension  of  the  finger,  in  some 
cases  leng-thening  of  the  tendon,  and  repair  of  the  wound  by  skin 
flaps,  can  restore  the  function  of  the  finger.  In  young  persons  good 
results  are  obtained  by  orthopedic  treatment,  when  the  scar  is  not 
very  extensive,  nor  hypertrophic,  nor  of  too  long  standing. 

In  contractures  of  central  origin,  especially  in  the  paralytic 
contractures  due  to  anterior  poliomyelitis,  nerve  transplantation,  and 
shortening  or  transplantation  of  tendons  may  be  performed.  Treat- 
ment by  massage,  electricity  and  orthopedic  apparatus  is  also  useful. 

In  contractures  of  peripheral  origin,  operative  interference,  free 
exposure  and  removal  of  the  compressing  agent  is  successful  if  the 
condition  is  not  so  old  that  the  nerve  is  hopelessly  destroyed:  and 
even  then  it  may  regenerate  in  time. 

By  far  the  best  treatment  of  ischemic  contraction  is  prophylaxis. 
'No  apparatus  that  causes  sivelliug,  cijauosis  of  the  fingers,  and  pain 
should  be  left  in  situ  for  any  length  of  time.  The  -patient's  com- 
plaints must  be  heeded. 

In  every  fracture,  a  careful  examination  must  be  made  to  detect 
injury  to  the  blood-vessels  or  nerves,  lest  they  later  should  be  unjustly 
charged  to  neglect  or  incompetency  of  the  attending  surgeon. 

Mild  cases  of  ischemic  retraction  may  be  improved,  almost  cured, 
by  long-continued  orthopedic  treatment  (Jones,  Say  re). 

The  other  forms  call  for  surgical  interference :  Tendon  lengthen- 
ing is  preferred  in  England,  resection  of  about  an  inch  and  a  half  of 
the  ulna  and  radius  (which  has  the  same  effect  as  tendon  lengthening, 
but  is  less  complicated  technically)   is  preferred  in  Germany.     In 

86 


Bockenheimer,  Atlas. 


Tab.  XLIX. 


Fig.  64.    Hallu.v  valgus  —  Hammerzehe  —  Arthrogene  Kontraktur. 


Rebnian  Company,  New- York. 


Amevioa,  Rure:eons  lean  to  hone  resect ioii,i\n(\  justly  dcvoti;  fonsider- 
able  attention  to  the  coiulitinii  of  iierres:  neurolysis,  freeing  of  the 
nervous  trunks  from  the  .sclerosed  masses  of  tissue  and  transposition 
above  the  fascia  are  necessary  when  there  is  nerve  implication. 

Aftei'-treatment,  massaf^-e,  clcitricity,  is  very  impoitant  and  must 
be  kept  up  for  a  long  time. 


Fig.  64  sliows  the  (iiil  ifiiid  (liridliiin  of  llic  liiy  (oc  called  hallux 
valgus.  The  second  toe  is  affected  with  the  deformity  known  as 
hammer-toe.  Besides,  thei-e  are  the  usual  sequehv  of  these  conditions, 
namely,  bidiions  and  corns;  and  also  dry  eczema  of  the  foot.  All  of 
which,  coupled  with  a  considerable  degree  of  flat-foot,  made  walking 
very  dillicidt  and  troublesome. 

The  deviation  of  hallux  valgus  is  generally  attril)uted  to  too 
pointed  shoes.  However  true  in  most  cases,  this  explanation  does 
not  hold  for  those  cases  of  hallux  valgus  seen  in  young  children  or  in 
peasants  and  workingmen  who  never  wore  tight  pointed  shoes. 
Heredity  may  here  play  a  role.  Contraction  of  the  extensor  hallucis 
maintains  the  deformity,  once  it  is  produced,  and  so  do  changes  in 
the  metatarso-phal(t)i(jc(d  joint  (atrophy,  inflammation,  arthritis 
deformans),  so  that  in  advanced  cases  reduction  of  the  deformity  is 
no  longer  possible  without  oi)eration. 

The  deviation  of  the  big  toe  may  be  as  much  as  50°,  so  that  the 
toe  crosses  the  second,  generally  over  (Fig.  64).  sometimes  under 
the  latter.  Over  the  projecting  metatarso-|)linlaugeal  joint,  a  bunion 
(inflamed  bursa)  develops,  also  corns  (Fig.  64),  while  the  head  of 
the  metatarsal  bone  is  the  seat  of  a  innrkcd  hi/iicrostosis  on  the  inner 
side,  so  that  the  articular  surface  instead  of  being  terminal  and  sym- 
meti'ical,  occupies  only  the  outer  half  of  the  head  of  the  bone.  The 
bunions  may  suppurate  and  o]ien  externally  (Fig.  64^.  An  ingrow- 
ing toe-nail  (comjiai'c  Fig.  99)  genci'ally  develops  on  the  outer  side 
of  the  great  toe  (Fig.  64). 

Hammer-toe  is  characterized  by  hi/pcrcrtcnsion  of  the  first 
phalanx  of  the  toe,  while  the  two  last  are  flexed;  the  result  is  that 
the  whole  pulp  of  the  toe  presses  directly  on  the  ground:  a  corn 
always  develops  there  (Fig.  64),  and,  on  account  of  pain,  walking 
becomes  dillficult.  llanuner-toe  has  been  attributed  to  contraction  of 
the  extensor  hallucis;  but  it  more  likely  is  a  condition  analogous  to 
Dupuytren's  contraction  (Fig.  60)  in  the  hand.  Owing  to  its  innocu- 
ousness,  and  the  ease  with  which  it  can  bo  sinuilateil,  it  has  been 

S7 


a  favorite  deformity  for  malingerers  who  want  to  avoid  military 
service.  However,  an  artificial  liammer-toe  is  only  a  forced  incurva- 
tion of  the  two  last  phalanges,  without  the  hyperextension  of  the 
first,  always  present  in  genuine  hammer-toe.  The  latter  usually 
affects  the  second  toe  (Fig.  64). 

Suhungual  exostoses  (Fig.  140)  also  occur  in  these  cases. 

Prophylactic  treatment  of  all  such  deformities  consists  in  atten- 
tion to  the  feet,  baths,  cutting  the  toe-nails  straight  instead  of  curved, 
wearing  jjroperly  fitting  boots,  etc. 

When  recent,  hallux  valgus  maj-  be  straightened  by  the  long- 
continued  use  of  splints.  But,  if  old,  if  changes  have  taken  place  in 
the  joint,  cuneiform  osteotomy  of  the  metatarsal  head  gives  the  best 
results. 

Hammer-toe  is  very  refractory  to  treatment.  Splints,  tenotomy, 
resection  may  be  attem^Dted ;  but  exarticulation  will  be  needed  in  most 
of  the  marked  cases. 

Exostoses  are  chiselled  off;  subungual  exostoses  require  prelim- 
inary removal  of  the  nail. 

(For  the  treatment  of  corns,  see  page  141.) 

In  the  case  represented  in  Fig.  64,  cuneiform  osteotomy  of  the 
metatarsal  head  was  performed;  the  bunions  and  corns  were  excised, 
the  second  toe  exarticulated,  and  the  eczema  treated  with  Hebra's 
ointment.     The  functional  result  was  excellent. 


Fig.  65  shows  a  case  of  rachitis,  affecting  the  whole  skeleton 
in  a  girl,  aged  4,  with  marked  incurvation  of  both  legs. 

Rachitis,  or  rickets,  is  a  disturbance  of  growth  affecting  the  whole 
skeleton.  Owing  to  faulty  nutrition  (the  exact  causes  of  which  are 
not  as  yet  fully  known,  but  in  which  fat  deficiency  and  carbohydrate 
excess  in  the  food  seem  to  play  an  important  part),  and,  maybe, 
owing  also  to  some  racial  predisposition  (negroes,  Italians),  the  lime 
salts  necessary  for  the  normal  growth  of  the  bone  are  not  properly 
assimilated  and  the  bones  soften.  In  the  epiphyses,  there  is  abnormal 
proliferation  of  cartilage  and  at  the  same  time  imperfect  ossification 
of  the  latter,  leading  to  the  formation  of  osteoid  tissue.  This  results 
in  the  development  of  the  epiphyseal  "beads,"  pathognomonic  of 
rickets,  and  considerable  deformity  in  all  parts  of  the  body. 

In  the  skull  the  disease  affects  chiefly  the  frontal  and  parietal 
bones.  In  extreme  cases  the  bones,  particularly  the  occipital,  are  soft 
and  flattened,  and  yield  to  pressure  (craniotabes).    In  other  places, 


Bnckpiilieimfr,  Atlas. 


Tab.  L. 


liti.  03.    RliacliiU>.         liiliMi.tinnc>  cruris  ulriubqiic. 


Rebnian  Company,  Ne«•-^■orl^. 


especially  tlie  frontal  and  parietal  eminences,  the  bones  are  thickened 
and  prominent,  givin.i":  the  so-called  "Olinnpic  fomhedfl"  The 
cranial  sutures  and  fontanelles  remain  open  far  k)nger  than  normal; 
the  upper  and  lower  jaws  are  iiM-e.irularly  develo|)cd  and  flattened  and 
the  implantation  df  tin.  Wr\U  is  ai.noniial  and  irrc-ular. 

The  weight  of  the  hudy  causes  l)eudiug  of  the  softene<l  l)0ues;  the 
spine  becomes  kyphotic  or  scoliotic;  the  antero-posterior  diameter  of 
the  thorax  increases,  while  the  transverse  diameter  decreases;  the 
sternum  is  projected  forw.n-d  {chicken  breast)  or,  on  the  contrary, 
sunken.  There  may  be  a  constriction  (rickety  girdle)  in  one  point  of 
the  thorax,  the  upper  part  of  which  seems  narrow,  because  the  costal 
margin  is  spread  out  and  widened.  The  junctions  of  the  cartilage 
and  bone  of  tlie  ribs  become  thickened  {rachitic  rosary). 

The  pelvic  bones  remain  small,  and  rachitic  pelvis  in  women  is  a 
frequent  cause  of  dystocia.  Lastly,  in  severe  eases,  or  if  the  child  is 
allowed  to  walk  during  the  period  of  softening  of  the  bones,  the  lower 
extremities  become  bent,  and  the  bones  are  liable  to  greenstick  frac- 
tures. Both  conditions  existed  in  the  little  patient  of  Fig.  65. 
Genu  valgum  is  the  most  frequent  deformity:  genu  varum  is  some- 
times observed.  Flat  foot  is  also  a  result  of  rickets,  and  so  are  most 
cases  of  coxa  vara.  In  severe  cases,  the  sul)jects  may  he  jiermaneutly 
dwarfs. 

The  disease  begins  with  anemia,  digestive  disturbance  and  diar- 
rhea, siveating  of  the  head,  and  marked  bulging  of  the  abdomen;  it 
tends  to  recovery  after  a  time,  when  normal  bone  replaces  osteoid 
tissue.  In  many  cases,  no  trace  is  left ;  in  others,  some  of  the  above- 
mentioned  deformities  persist  for  life. 

The  prognosis  of  rickets  is  favorable  per  se;  liut  rickets  neverthe- 
less remain  an  important  factor  of  infantile  mortality,  owing  to  the 
physical  and  mental  backwardness  of  the  subjects  aiTected,  of  their 
lesser  resistance  to  intercurrent  infections,  and  to  the  greater  gravity 
of  pulmonary  and  cardiac  affections  in  those  whose  thorax  is  de- 
formed. 

Uiiiiino.iis   and    Trcntiiiriil 

There  is  usually  little  trouble  in  recognizing  rachitic  children, 
with  their  characteristic  facies,  pot  belly,  and  epiphyseal  heads. 

Hereditary  syphilis  (which  Parrot  thought  the  main  cause  of 
rickets,  a  view  untenable  nowadays)  affects  fewer  bones,  particularly 
the  tibia,  and  bone-lesions  are  almost  always  associated  witli  other 
signs  of  congenital  syphilis  (interstitial  keratitis,  Hutchinson  teeth, 
positive  Wassermau)!  reaction). 

89 


Pott's  disease  differs  from  rickety  scoliosis  by  the  presence  of  a 
shari?  angular  bend,  instead  of  the  long  curve  of  the  rachitic  deform- 
ity; besides  there  are  points  painful  on  pressure-  and  a  marked 
rigidity  of  the  diseased  segment,  and  no  other  bony  deformities. 

Osteomalacia  is  a  softening  of  the  bones,  seen  particularly  in 
women,  in  adult  life,  never  in  young  children. 

Treatment 

The  treatment  of  rickets  at  first  is  purely  dietetic  and  liygienic; 
correct  feeding,  fresh  air,  salt  baths,  and,  maybe,  phosphorus. 

Tlie  surgical  treatment  of  rachitic  deformities  must  never  be 
undertaken  before  the  process  has  stopped  and  spontaneous  recovery 
and  straightening  of  bone  has  progressed  as  far  as  it  will  go.  To 
ascertain  this.  X-ray  examinations  are  useful ;  in  active  rickets  the 
epiphyseal  lines  appear  wide  and  irregular,  sometimes  with  incom- 
plete fractures ;  while,  when  the  disease  has  come  to  a  standstill,  the 
epiphyseal  lines  have  become  regular,  and  the  cortex  appears  as  thick 
as  the  deeper  parts. 

Eachitic  deformities,  being  quite  varied,  may  call  for  a  number 
of  operative  procedures,  on  which  we  do  not  intend  to  dwell  in  detail 
here.  Genu  valgaim  and  too  marked  incurvation  of  the  tibia,  as  shown 
in  Fig.  64,  indicate  cuneiform  osteotomy. 


Fig.  66  shows  a  pseudarthrosis,  an  ununited  oblique  fracture  of 
the  tibia  above  the  malleolus,  in  a  man  60  years  of  age.  Although 
the  injury  dated  back  two  years,  the  distal  part  of  the  tibia  was  freely 
movable  with  the  foot.  The  X-rays  showed  an  overlapping  of  the 
fragments  and  a  united  fracture  of  the  distal  end  of  the  fibula  a  few 
centimetres  above  the  external  malleolus.  The  nature  of  the  injury 
Tiad  not  been  diagnosed. 

The  causes  of  delayed  union  of  fractures  may  be  general  (rachitis, 
syphilis,  tuberculosis,  pregnancy,  old  age)  or  local  (infection  in  com- 
pound fractures,  interposition  of  soft  parts,  periosteum  or  muscle). 

Pseudarthrosis  occurs  in  the  leg,  chiefly  after  oblique  fractures 
with  dislocation  or  comminuted  fractures;  in  the  thigh  (neck  of  the 
femur)  and  upper  ai'm  (humerus)  after  transverse  fractures  also.  In 
the  arm,  interjiosition  of  soft  parts  is  the  chief  cause.  In  fractures 
of  the  femoral  neck,  particularly  those  of  the  intracapsular  variety, 
non-union  was  especially  frequent,  and  it  was  very  generally  blamed 
in  former  days  on  the  old  age  of  the  patients,  but  Whitman  has  shown 

90 


Bockciilieiiner,  Atlas. 


Tab.  I.I. 


Fif.  06.    L.uxatio  cum  Inicuna  cruris  —  Pseudartlirosis. 


Kcbiinii  Comp.iny,  Nc\v-\'oil< 


conclusively  tliat  tlie  role  of  senile  rarefnction  of  the  bone  has  beea 
considerahly  exn,s:,e:erate(l ;  llinl  iiii)>t  n\'  tlir  pseudartliroses  were  due 
to  the  fact  that  the  aceeiitcd  trmluR'nt  iIhI  not  bring  the  two  frag- 
ments in  exact  apposition ;  that,  if  the  extreme  abduction  treatment  is 
applied,  coaptation  is  obtained,  and  i)ony  union  follows,  even  in  old 
people. 

This  emphasizes  the  necessity,  in  cases  of  non-united  fractures, 
of  carefully  analyzing-  all  data,  and  of  ascertaining:  ail  local  con- 
ditions, before  we  have  a  right  to  attribute  non-union  to  a  .sreneral 
cause.     In  this  respect  X-ray  examinations  are  invaluable. 


Simple  delayed  union  may  be  accelerated  by  passive  hyperemia, 
Bier's  blood  injection  between  the  frag-meuts  {Kiliani,  Lyle),  and, 
perhaps,  by  the  internal  administration  of  calcium  salts. 

Carrel's  recent  work  shows  that  l)one  reparation  may  be  consider- 
ably hastened  by  the  direct  application  on  the  line  of  fracture  of  pulp 
of  glandular  parenchyma,  chiefly  of  the  thyroid  gland. 

Non-union  depending  on  local  conditions  calls  for  a  correction  of 
the  latter:  interposed  soft  parts  must  be  removed,  bone  ends  must 
be  freshened  and  brought  in  correct  position,  and  maintained  there, 
either  by  a  plaster  of  Paris  cast,  or  by  plating. 

The  operative  treatment  of  fractures  has  been  much  advanced  in 
late  years;  Lane's  plates  (or  better,  the  modified  vanadium  steel 
plates  of  Sherman),  when  properly  used,  give  excellent  results  in 
ununited  fractures,  or  in  those  in  which  the  displacement  cannot  be 
corrected  by  the  other  methods  of  ti'eatment.  A  strict  asepsis-  is 
necessary;  hence  the  operative  treatment  of  fractures  is  not  applic- 
able in  ca.ses  of  non-union  in  infected  compound  fractures  of  long 
standing. 

In  old  fractures,  and  in  those  near  joints,  resection  may  become 
necessary  to  insure  reduction. 

When  syphilis  is  suspected,  mixed  treatment  or  salvarsau  should 
be  administered. 


91 


NAEVI 

Figs.  67,  68  and  69  show  naevi  and  a  condition  of  cutaneous 
nerves  sometimes  found  in  conjunction  with  them. 

Ncevi  are  developmental  defects  of  the  skin  characterized  by  an 
excessive  growth  of  pigment  {figinentary  ncevi,  Figs.  67  and  68)  or 
of  vascular  tissue  {vascular  ncevi,  Figs.  75  and  76). 


Fig.  67  shows  a  large  pigmentary  hairy  nsevus,  wliich  was  present 
at  birth  and  increased  in  size  till  the  age  of  puberty.  The  borders  are 
smooth,  but  the  central  parts  are  warty  {ncevus  verrucosus).  The 
color  is  blackish  brown  in  the  center  and  brown  at  the  periphery. 


Fig.  68  shows  a  slightly  pigmented  nsevus  extending  over  most 
of  the  forearm,  with  a  bluish-red,  irregular  elevation  in  the  center. 
This  nsevus  was  present  at  birth.  Small  pigment  spots  were  scattered 
over  the  whole  body.  The  bluish-red  elevation  in  the  centre  was 
formed  by  a  fibroma  of  the  sheath  of  a  large  subcutaneous  nerve.  In 
addition,  there  were  fibromata  along  the  course  of  the  principal 
nerves  of  the  arm  (neuro-fibromata)  (on  the  upper  arm  and  the 
axilla,  of  the  size  of  a  walnut)  and  multiple  cord-like  formations 
{plexiform  neuroma)  could  be  felt  under  the  nsvus.  There  were  also 
small  soft  nodules  in  the  skin  (fibromata  mollusca).  All  these  forma- 
tions had  appeared  later  than  the  na?vus,  but  had  been  present  many 
years. 


Fig.  69  shows  a  similar  condition  in  a  girl  aged  20. 

The  whole  of  the  right  half  of  the  scalp,  the  right  side  of  the 
forehead  and  the  ear  are  the  seat  of  a  lobulated  growth  (elephantiasis 
nervorum)  fixed  on  the  head  like  a  cap.  The  growth  was  congenital, 
and  on  its  surface  are  numerous  pigTnent  spots  and  soft,  small,  pain- 
less tumors  (fibromata  mollusca).  Numerous  cord-like  formations 
were  found  in  it  by  palpation  (plexiform  neuroma).  This  is  a  typical 
location  for  the  disease;  the  nape  of  the  neck  and  the  back  are  also 
affected. 

!)2 


i;i>fl<ciilieinicr,  Atlas. 


Tab.  I.II. 


Fig.  67.    Nacvus  pigmentosus  pilosus. 


Rebman  Company,  New-York. 


Bockenheimer,  Atlas. 


Tab.  Lin. 


Fig.  68.   Naevus  neuromatosus  -  Neurofibroma  cutis. 


Rebman  Company,  New- York. 


AS  seen  from  llic  preccdin-,'  (Icscription,  various  names  have  been 
bestowed  upon  this  condition  about  the  etiology  of  which,  barring 
cougemtaUty,  hereditary  predisposition,  and  a  possible  influence  of 
trauma  and  repeated  irritations,  nothing  is  known:  elephantiasis 
nervorum,  fibroma  molluscum,  plexifonn  neuroma,  generalized  neuro- 
fibromatosis.' None  of  these  names  is  absolutely  adequate  for  the 
whole  of  the  disease,  but  each  is  partly  justified  by  some  of  the 
anatomical  alterations  found,  as  we  shall  presently  explain. 

Neuro-fibromatosis  is,  perhaps,  the  best  name,  because  the  chief 
lesions  are  multiple  small  fibromata  along  the  course  of  superficial 
nerves.  However,  these  are  fibromata  of  the  nerve-sheaths,  for  which 
the  term  neuro-fibroma  is  not  altogether  proper,  because  they  consist 
of  fibrous  tissue  only,  without  any  proliferation  of  nerve-fibers.  These 
multiple,  small  fibromata  are  generally  disseminated  over  the  whole 
body,  forming  small,  soft,  subcutaneous  tumors  when  they  affect  the 
fine  cutaneous  nerves,  and  are  associated  with  numerous  pigment 
spots.  The  small  tumors  may  lie  so  closely  together  that  the  skin 
assumes  a  finely  lobulated  appearance  (temples  (see  Fig.  69).  neck 
and  back).  This  condition  has  been  termed  elephantiasis  nervorum,. 
because  with  the  fibrous  tissue  formation  there  are  numerous  lym- 
phatic vessels. 

Besides,  in  distinction  to  these  small,  soft,  multiple  fibromata,  there 
may  be  fibromata  of  the  larger  nerve  trunks,  which  appear  as  hard 
fusiform  tumors  of  the  sheaths  of  the  cutaneous  (Fig.  68)  or  sub- 
cutaneous nerves.  They  are  very  painful  on  pressure  and  may  cause 
functional  disorders  (paresthesia,  for  instance). 

In  addition  to  these  two  forms  of  fibroma,  there  may  be  in  other 
points  true  neuromata,  which  resemble  cirsoid  aneurism,  hence  the 
name  of  cirsoid  or  plexiform  neuroma.  These  are  formed  of  twisted 
cords,  which  may  form  an  inextricable  network  of  nerve  cords  and. 
contain  nerve  fibers,  while  the  above-mentioned  types  of  lesions  do 
not,  despite  the  name  bestowed  upon  them. 

Diagnosis 

The  diagnosis  of  nsvi  is  a  very  simple  matter. 
Von  Re(ldi)ighausen's  disease,  with  its  multiple  elements,  is  so 
characteristic  that  no  hesitation  is  possilile. 

Treatment 

NcTvi  on  exposed  pai-ts  of  the  body  should  be  excised,  for  cosmetic 

'Or,  simply,  ton  lirrlKlinfihanscn's  disease,  because  this  writer  was  the  first  to  draw  the 
attention  to  the  relation  l)etween  disseminated  pigment  spots,  certain  lesions  of  peripherat 
nerves  and  mental  liackwardness. 

93 


reasons.  Eemoval  of  all  naevi  showing  inflammation  or  a  tendency 
to  degeneration  is  also  indicated  (about  melanotic  tumor  evolution, 
see  Figs.  17,  23,  28,  and  pages  20,  25,  36). 

Electrolysis  may  be  used  in  small  nsevi.  But  we  must  guard 
against  methods  that  do  not  destroy  thoroughly,  because  they  simply 
irritate  and  promote  malignant  changes.  X-rays  are  sometimes  bene- 
ficial. Pusey  has  found  freezing  with  carbon  dioxide  snow  (see 
farther,  about  vascular  nsevi,  page  102)  a  very  good  method. 

Njbvus  neuromatosus  should  only  be  excised  when  it  shows  papillo- 
matous proliferations  or  when  fibromata  or  a  plexiform  neuroma  are 
situated  beneath  it. 

Isolated  fibromata  of  the  nerve  sheaths  can  generally  be  excised 
without  injuring  the  nerve ;  but  in  large  fibromata  the  nerve  may  have 
to  be  resected,  with  subsequent  suture.     Recurrence  is  rare. 

Multii^le  fibromata  are  apt  to  recur  after  operative  interference. 
They  should  be  removed  only  when  rapidly  growing,  as  they  may 
then  undergo  sarcomatous  or  myxosarcomatous  proliferation. 

Plexiform  neuromata  must  be  completely  extirpated,  as  recurrence 
takes  place  if  any  part  is  left  behind.  At  the  same  time,  the  thick- 
ened skin  should  be  removed  if  it  shows  elephantiasic  changes.  In 
extensive  cases  the  operation  may  be  done  at  several  sittings.  This 
was  done  in  the  case  represented  in  Fig.  69.  In  that  of  Fig.  68  a 
very  painful  fibroma  in  the  axilla  was  first  removed,  and  the  nsevus 
neuromatosus  was  excised  later. 


94 


Bockenlicimer,  Atlas. 


Tab.  I.IV. 


Rebman  Company,  New- York. 


LESIONS   OF  THE  LYMPHATIC   AND 
VASCULAR  SYSTEMS 

Fig.  70  shows,  ill  ,111  (lid  mnii,  llic  dironic  congestion  of  the  flush 
tirea  oT  the  fneo  with  nciic  lesions  ;iii(l  dilatation  of  si<in  capilhiries, 
which  constitutes  acne  rosacea;  and  the  irregular,  lobular  tliicken- 
ing  of  the  nose,  which  is  called  rhinophyma  and  is  the  result,  in  some 
cases,  of  long-standing  rosacea. 

Rosacea  is  an  aticiioneurotic  (listitrljdiicc,  generally  depending  on 
faulty  diet  or  metabolism  (alcoholism,  dyspepsia).  When  the  pink 
coloration  of  the  nose  and  adjacent  area  has  existed  for  some  time, 
aoie  lesions  develop,  and  permanent  telangiectases.  Finally,  the 
hypertrophic  thickening  of  the  skin,  at  first  regular,  is  modified  by  the 
development  of  large  sebaceous  follicles,  with  dilated  i)ores,  from 
which  yellow  secretion  can  be  expressed,  which  finally  cause  rhino- 
phyma. Once  they  are  developed,  rosacea  and  rhinophyma  have  no 
tendency  to  regression:  they  cause  no  subjective  symptoms.  This 
condition  is  more  frequent  in  old  people. 

Diagnosis 

Rosacea  is  easy  to  recognize  from  simple  acne  by  its  limitation 
to  a  special  area  of  the  face. 

Rhinophyma  is  a  typical  lesion  with  its  dilated  orifices  of  seba- 
ceous follicles,  and  the  greasy  appearance  of  the  skin  due  to  exag- 
gerated secretion  of  these  follicles. 

Rhinoscleroma  causes  softer  tumors,  which  soon  ulcerate,  and  may 
destroy  the  whole  face. 

Lupus  is  distinguished  by  its  a]i]ile-jelly  nodules,  ulceration  and 
scarring. 

Tubercular  si/pliilidcs  of  the  nose  (Fig.  120)  are  less  symmetrical 
and  nlcerate. 

A  pachijrlernuitous  condition  may  result  from  repeated  attacks  of 
erysipelas  (see  i)age  129),  but  differs  from  rhino])liynin  in  not  affect- 
ing the  nose  any  more  than  the  rest  of  the  face. 

Treatment 

The  correction  of  all  dietetic  errors  is  important  in  rosacea.  AVash- 
ing  the  face  with  lukewarm  water  and  soa]i,  and  ai>])lyiug  lotio  alba 

05 


is  useful.  Telangiectases  are  treated  as  will  be  said  later  (page  102). 
X-rays  favorably  influence  the  hypertrophy  of  the  skin  and  sebaceous 
follicles.  However,  when  rhinophyma  has  attained  the  development 
shown  in  Fig.  70  decortication  of  the  nose  with  the  knife  is  the 
only  treatment.  Owing  to  the  very  abundant  blood  supply  of  the 
region,  and  the  hypertrophy  of  the  epidermis,  the  wound  heals  very 
promptly,  the  scarring  is  trifling  and  results  are  excellent. 


Fig.  71  represents  a  case  of  elephantiasis  of  the  penis,  in  a 

man  of  40. 

Elephantiasis  (or  pachydermia)  is  a  chronic,  diffuse  hyperplasia 
of  the  skin  and  subcutaneous  tissue  due  to  persistent  obstruction  of 
the  lymph  channels.  In  the  case  shown  in  Fig.  71,  the  obstruction 
had  been  caused  by  bilateral  extirpation  of  the  ing-uinal  glands.  The 
swelling  had  begTin  soon  after  the  operation  and  had  progressed 
slowly,  the  chronic  course  being  interrupted  several  times  by  acute 
exacerbations,  which  subsided  after  a  few  days'  rest  in  bed. 

The  thickening  of  the  skin  was  not  uniform,  but  lobulated.  It  felt 
soft  and  spongy.  In  such  cases  there  is  a  marked  fibrosis  of  the 
subcutaneous  tissue  and  dilatation  of  the  blood  and  lymph-vessels, 
the  latter  being  the  primary  factor. 

The  skin  was  pigmented  and  the  scrotum  covered  with  crusts,  and 
there  were  numerous  depressions,  as  in  rhinophyma.  There  was  no 
pain. 

In  tropical  countries,  elephantiasis  results  from  a  specific  cause, 
namely,  the  blocking  of  lymphatics  by  the  filaria  sanguinis  honiinis 
and  kindred  parasites.  In  our  climate,  elephantiasis  is  not  a  specific 
disease,  but  only  a  symptom,  which  depends  on  manifold  causes; 
chronic  edema,  or  eczema,  recurrent  erysipelas,  syphilitic  and  tuber- 
culous lesions,  varicose  ulcers,  phlebitis  and  thrombosis  of  veins,  and 
pyogenic  infections  of  the  skin.  We  have  already  mentioned  double 
extirpation  of  the  inguinal  glands  (Fig.  71)-  A  double  radical  opera- 
tion for  hernia  has  sometimes  had  the  same  result. 

The  legs  are  the  parts  most  frequently  affected;  next  come  the 
male  and  female  genitalia.  In  prostitutes,  the  labia,  clitoris  and 
perineum  sometimes  become  affected  with  elephantiasis  from  gonor- 
rheal discharges  and  syphilis. 

The  tissues  feel  at  first  soft,  but  afterward  become  firm  and  elastic. 
Parts  having  undergone  pachydermic  alterations  are  more  liable 
than  healthy  tissue  to  intercurrent  infections.    Eepeated  attacks  of 

96 


Bockciiliciiiier,  Atlas. 


Tab.  L\'. 


I  i.^'.  71.    I:lcplianti;-isis  penis  l\iiipliaiigiectalic;i. 


RcliMi.iii  Company,  Ncw-N'ork. 


Bockenheinier,  Atlas. 


Tab.  LVI. 


fig.  72.    Ulcus  cruris  varicosum  —  Elephantiasis,  Pachydermia  acquisita. 


Rebman  Company,  New-York. 


lyiiil)liaiisiti.s  are  oominon,  after  eacli  of  wliich  tliere  is  an  increase 
of  tlie  elei)liantiasis.  lOczema,  bulla\  pif^niented  spots,  scabs  and 
crusts,  condylomatous  or  papillomatous  proliferations,  or,  finally, 
ulceration,  may  occur  on  the  surface.  Ulceration  causes  intolerable 
sufferinp::  otherwise,  the  condition  is  painless  and  causes  inconven.- 
lence  only  by  its  weight  or  when  it  prevents  walking  on  account  of 
its  size. 

Diagnosis 

It  is  hardly  necessaiy  to  dwcli  on  tlio  differential  features  existing 
between  ordinary  ek'iihantiasis  and  the  so-called  " vlrpUantiasis 
nervorum"  of  von  Rcckliiighintsen's  disease  (Figs.  68  and  69).  The 
other  symptoms  of  the  latter  condition,  fibromata,  neuromata,  dissem- 
inated pigment  spots,  do  not  leave  room  for  any  hesitancy. 

In  partial  giantism  there  is  an  overgrowth  of  all  the  tissues, 
including  the  bones,  dating  back  to  early  infancy. 

The  recognition  of  the  cause  is  important.  The  diagnosis  of 
endemic  elephantiasis  is  settled  by  the  detection  of  the  parasite  in 
the  blood  taken  at  night. 

Treatment 

All  lesions  of  the  inguinal  glands,  especially  if  bilateral,  must 
receive  prompt  attention  in  order  to  avoid  lymphatic  oljstruction. 
All  conditions  enumerated  above,  susceptible  of  leading  to  pachy- 
dermia, must  be  carefully  treated. 

Recent  and  light  cases  may  be  improved  by  elevation,  massage 
and  compression.  More  extensive  eases  have  to  be  treated  by  cunei- 
form excision.     This  was  performed  in  the  case  shown  in  Fig.  71. 


Fig.  72  shows  an  elephantiasic  thickening  of  the  toes  developed 
in  connection  with  a  varicose  ulcer  of  the  log.  The  toes  are  enor- 
mously thickened  and  constricted  in  places;  the  whole  foot  is  also 
enlarged  and  the  arch  of  the  foot  is  obliterated.  The  thickening  of 
the  foot  continually  increased  and  extended  to  the  ankle.  Frequent 
attacks  of  erysipelas  aggravated  the  affection. 

The  varicose  ulcer  is  situated  on  the  inner  side  of  the  leg,  at  its 
lower  third,  and  extends  nearly  over  the  whole  circumference. 

Varicose  ulcers  occur  generally  in  old  people  of  the  poorer 
classes,  who  cannot  take  proper  care  of  their  varices  and  have  to  do 
much  standing;  uncleanliness  makes  matters  worse.  All  diseases  of 
the  nervous  system  and  arteriosclerosis  may  cause  the  development 

97 


of  trophic  ulcers  (see  Fig.  138),  wliicli  are  not  unlike  varicose  ulcers^ 
but  are  still  more  refractory  to  treatment  than  the  latter. 

Varicose  ulcer  of  the  leg  is  characterized  by  its  irregular,  slightly 
raised  edges,  while  the  surrounding  parts  may  be  covered  with  scat- 
tered, flabby  granulations,  crusts  and  blood-scabs  (Fig.  72).  Around 
the  base  of  the  ulcer  are  fine,  bluish,  dilated  veins,  from  which  fre- 
quent bleeding  takes  place.  The  ulcer  is  often  connected  with  a  rup- 
tured varicose  vein. 

In  small  ulcers  temporary  healing  may  take  place,  but  the  scar  is 
very  thin,  generally  pigmented,  and  gives  way  again  on  the  slightest 
cause ;  after  which  no  further  healing  usually  takes  place,  but  the 
ulcer  continues  to  extend.  The  whole  neighborhood  of  the  ankle  joint, 
and  even  the  whole  leg,  may  be  involved  in  ulceration,  which  often  has 
a  sanious  discharge.  In  extensive  ulcers  there  is  generally  severe 
pain  and  the  leg  becomes  more  or  less  useless  owing  to  the  extent 
of  the  ulcer  and  the  elephantiasis. 

Differential  diagnosis 

Large  ulcers  with  sanious  discharge  may  suggest  carcinoma, 
owing  to  their  hard  borders,  but  in  carcinoma  there  are  always  irreg- 
ular, hard-tumor  masses  in  the  whole  extent  of  the  ulcer.  The  possi- 
bility of  transition  of  an  ulcer  of  the  leg  into  carcinoma  must  be  borne 
in  mind  (see  Fig.  20)-  In  doubtful  cases,  always  excise  a  piece  of 
the  indurated  edge  for  microscopical  examination. 

Gummatous  ulcer,  frequent  on  the  leg,  is  more  regular,  often 
circular,  and  has  a  punched-out  appearance.  The  base  of  the  ulcer  is 
smooth  and  covered  with  a  tenacious,  yellowish,  fatty  core.  The  ulcer 
is  generally  less  extensive  and  there  is  no  bleeding.  Anamnesis  and 
the  Wassermann  reaction  may  clear  up  the  diagnosis.  The  tibia  may 
show  some  of  the  characteristic  features  of  gummatous  osteitis. 

Tubercular  ulcers  are  rare  on  the  leg.  However,"  their  thin, 
undermined  edges,  and  particularly  anemic  appearance  are  sufficient 
to  enable  one  to  recognize  them  without  difficulty. 

Treatment 

Inveterate  varicose  ulcers  are  difficult  to  heal,  owing  to  the  gen- 
erally very  poor  condition'  of  the  circulation  in  the  limbs  affected. 
Rest  in  bed,  with  the  foot  elevated,  is  absolutely  necessary.  An 
enormous  number  of  substances  have  been  extolled  as  dressings.  The 
best  are  styrax,  balsam  of  Peru  and  especially  scarlet  red  salve  (see 
page  73). 

98 


Bockenheimer,  Atlas. 


Tab.  LVII. 


Fig.  73.    Detachment  of  tlie  Skin. 


Rebman  Company,  New-York. 


Sinn  oraffnig  (see  Fig.  55  .in,!  pajye  7:3)  may  be  resorted  t..  Jn 
obstinate  cases,  Morcschi  lias  ailvu.-ated  a  circumferential  incision  of 
the  skin  and  subcutaneous  tissue  of  tlie  le^  above  tlie  ulcer.  Excision 
of  the  wliole  ulcer  with  repair  of  the  defect  l)y  means  of  the  skin  flap 
has  also  been  done. 

Oporativo  treatment  of  tlie  varices  (for  which  see  Fig.  83  and 
pn-c  1].!)  i<  ,,rteii  necessary  to  bring  about  the  cicatrization  of 
an  ulcer. 


Fig  73  shows  a  detachment  of  the  skin,  lliat  is,  a  sul)cutaneous 
separation  of  the  skin  from  the  subjacent  structures,  with  the  special 
variety  of  effusion  dcstq-ibod  by  Morel  LacalK-e  under  the  name  of 
traumatic  effusion  of  serosity.  Jt  is  tlie  result  of  a  blow  on  the 
left  elbow,  which  acted  tuugeutmllii,  so  that  the  skin  was  not  injured, 
but  slid  on  the  resistant  underlying  fascia;  the  connective  tracts 
uniting  the  skin  to  the  fascia  were  torn  and  with  tliem  innumerable 
lymph  vessels,  from  which  exuded  the  clear,  yellowish  fluid,  which 
was  evacuated  by  tapping  a  few  days  after.  The  absence  of  blood 
showed  that  no  important  blood  vessels  had  been  torn.  If  any  blood 
vessels  have  been  torn  in  such  an  injury,  the  result  is  an  ordinary 
hematoma,  which  promptly  undergoes  spontaneous  resorption,  while 
those  lymph  effusions  persist  indefinitely  with  slight  variations  from 
day  to  day. 

The  above-described  mechanism  explains  why  such  a  condition 
is  more  frequent  in  the  thigh  on  account  of  the  tough  fascia  lata,  and 
on  the  abdomen.  A  carriage-wheel  passing  over  the  thigh  gives  the 
ideal  condition  for  its  production.  The  effusion  causes  a  fluctuating 
bulging  of  the  skin,  which  never  becomes  very  tense.  There  is  no 
discoloration  of  the  skin.  This,  with  the  indefinite  persisfenci)  and 
the  fact  that  the  effusion  develops  slowly,  and  not  immediately, 
differentiates  lymph  effusions  from  hematomata. 

The  treatment  is  repeated  aseptic  tapping  followed  by  com- 
pression.   Incision  ought  to  be  resorted  to  only  in  case  of  suppuration. 


Fig.  74  shows  the  mixed  blood  and  lymph  effusion  in  the  auricle 
known  as  othematoma.  In  the  auricle  (as  sometimes  in  the  nasal 
septum)  we  find  the  condition  already  stated  as  essential  (see  above) 
for  the  production  of  such  collections,  namely,  a  tense  structure  (iiere, 
the  cartilage),  over  which  the  skin  can  slide  when  struck  tangentially. 

99 


othematoma  occurs  especially  in  tlie  upper  half  of  the  auricle, 
and  is  found  in  the  mentally  affected  as  the  result  of  ill-treatment 
by  blows  on  the  ear,  etc. ;  in  workmen  who  carry  on  the  shoulder  loads 
which  graze  the  ear ;  in  carpenters  through  carrying  planks ;  in 
butchers  through  carrying  troughs,  etc.  It  is  also  a  common  injury 
in  boxers  {caulifloiver  ear  results  from  repeated  othematomata)  and 
in  acrobats. 

It  generally  causes  little  trouble.  As  already  stated  about  Fig.  73 
(page  97)  blood  effusion  is  indicated  by  the  rapid  development  of  a 
tense,  dark-blue  swelling,  which,  after  a  time,  subsides.  Lymph 
effusion  is  indicated  by  a  swelling  which  does  not  develop  till  some 
time  after  the  injury  and  has  little  tendency  to  subside;  the  skin  is  not 
discolored.  Lymph  effusion  in  the  ear  is  nearly  always  slightly  mixed 
with  blood,  and  always  forms  a  tense  swelling,  in  distinction  to  lymph 
effusions  in  other  parts  of  the  body  (page  97). 

Blood  and  lymph  effusions  in  the  auricle  may  undergo  chronic 
inflammation,  which  first  causes  thickening,  later  on  atrophy  and 
necrosis  of  the  auricle,  with  considerable  mutilation.  If  the  skin  is 
much  abraded,  the  effusion  may  become  septic,  with  consequent  de- 
struction of  the  cartilage. 

Differential  diagnosis 

Cavernous  angioma,  which  often  occurs  in  the  upper  part  of  the 
auricle,  somewhat  resembles  hematoma.  However,  angioma  is  con- 
genital ;  it  can  be  reduced  by  pressure  and  has  a  special  bluish  colora- 
tion (see  Figs.  36,  80  and  81).  Other  vascular  anomalies  (such  as 
n<svi,  see  Fig.  76)  are  usually  present  in  the  neighborhood  of  the 
tumor. 

7'reatnient 

Prophylactic  treatment  consists  in  the  wearing  of  ear  caps.  The 
hematoma  must  be  protected  from  injuries  which  may  cause  septic 
infection  of  the  effusion.  It  undergoes  spontaneous  resolution,  but 
more  slowly  than  in  other  places.  Lymph  effusions  recur  after  re- 
peated puncture ;  immediate  compression  by  strips  of  adhesive  plaster 
and  massage  are  useful  in  most  cases.  Massage  brought  down  the 
othematoma  shown  in  Fig.  74,  after  it  had  recurred  after  tapping. 


Figs.  75,  76,  80  and  81  (and  also  Fig.  36)  show  different  types 
of  hyperplastic  localized  lesions  of  the  vascular  system,  ncavi  and 
angiomata. 

100 


Bockenheimer,  Atlas. 


Tab.  LVIII. 


O 


Rebman  Company,  New- York. 


Fig.  75  shows  a  lypical  simple  cutaneous  angioma  of  the  nape 

of  tlie  neck,  wliicli  a[)i)eared  as  a  i-eil  sjjot  soon  aTlcr  l)irtli  and  ceasod 
growing  after  the  second  year.  The  horders  of  the  growth  are  red 
and  show  small,  ramifying  hlood-vessels.  The  center  is  hluish-red 
and  partly  covered  l)y  noi'mal  skin.  The  tumor  was  soft,  freely 
movable  over  subjacent  jiarts  and  sharply  defined. 

Fig.  76  sliows  a  vascular  naevus  (so-called  "wine  spot")  cover- 
ing almost  the  whole  of  the  left  side  of  the  face  of  a  cliild. 

Fig.  80  shows  a  subcutaneous  cavernous  angioma,  which  often 
occurs  in  the  region  of  tlie  rectus  abdominis  muscle,  sometimes  in  the 
muscle  itself.  The  skin  is  already  destroyed  over  the  blue  parts  of 
the  tumor,  and  is  of  a  livid  color  at  the  periphery.  The  growth  is 
encapsulated  and  freely  movable  over  the  abdominal  fascia  (in  dis- 
tinction to  infiltrating  cavernoma).  In  some  parts  the  cavernous 
spaces  can  be  seen  through  the  surface.  In  the  center  of  the  angioma 
the  skin  is  yellow  in  some  parts  and  brown  in  others.  The  growth 
was  soft,  elastic  and  compressible;  in  some  places  throm])osis  with 
consequent  shrinking  had  taken  place.  The  growth  had  remained 
stationary  for  a  year. 

Fig.  81  shows  a  combination  of  cutaneous  and  subcutaneous 

angiomata  with  telangiectases,  afl'ecting  the  leg.  The  telangiec- 
tases are  seen  as  red  spots,  in  some  places  arranged  in  the  form  of 
a  wreath.  There  is  also  an  extensive  subcutaneous  angioma,  of  a 
bluish-red  color,  with  more  or  less  normally  colored  skin  in  the 
central  parts,  and,  at  the  lower  part  of  the  subcutaneous  angioma, 
there  are  cutaneous  hemangiomata,  appearing  as  more  elevated,  round 
formations  in  the  skin,  resembling  the  simple  cutaneous  angioma 
represented  in  Fig.  75.  In  the  whole  region  of  the  subcutaneous 
angioma  fine  ramifying  blood-vessels  can  be  seen. 

These  hyperplastic  conditions  of  the  vascular  system  may  be 
divided  into : 

Telangiectases,  simple  dilatations  of  pre-existing  vessels. 

Angiomata,  in  which  there  is  foi-mation  of  new  blood-vessels. 
Both  may  coexist  as  seen  in  Fig.  81. 

Telangiectases  can  hardly  be  classed  as  tumors  despite  their  rela- 
tions with  the  other  kinds  of  angioma  as  thoy  consist  in  dilatation, 
lengthening  and  tortuosity,  rather  than  new  I'mination,  of  vessels. 

For  vascular  n:pvi,  the  point  is  much  more  debatal)le.  as  those 
are  unquestionably  new  formations  and  not  a  simple  dilatation  of  the 

101 


skin  capillaries,  though  many  authors  have  considered  them  as  the 
greatest  degree  of  telangiectases.  This  fact  is  demonstrated  by  the 
injection  of  nsevi  from  their  supplying  blood-vessels,  without  at  the 
same  time  injecting  the  capillaries  of  the  surrounding  skin. 

For  angiomata  of  the  cavernous  type  there  can  be  no  question  that 
we  have  to  deal  with  a  real  vascular  tumor  (not  only  in  the  clinical 
sense  of  the  word)  with  continuous  tendency  to  encroach  upon  neigh- 
boring organs.  Now,  cavernous  angioma  is  simply  the  highest  degree 
of  the  lesions  found  in  nasvus ;  it  is,  in  fact,  a  cavernous  nasvus  having 
large  blood  spaces  instead  of  capillaries,  and  often  develops  from  a 
simple  flat  nasvus  (see  page  75). 

The  form  known  as  racemose  or  plexiform  angioma  also  almost 
always  consists  in  a  dilatation  of  a  vascular  region,  not  a  true,  new 
formation  of  vessels.  It  is,  therefore,  better  to  give  the  name  cirsoid 
aneurism  to  these  formations,  which  are  usually  congenital  and  due 
to  fetal  remains,  but  sometimes  traumatic.  Lastly,  neither  aneurisms 
nor  varices  belong  to  true  vascular  tumors. 

A  form  described  by  Ziegler  under  the  name  of  hypertrophic 
angioma  is  best  named  hemangio-endothelioma,  as,  in  addition  to 
new  formation  of  vessels,  there  is  extensive  proliferation  of  the 
endothelium. 

Nsevi  and  angiomata  are  congenital  conditions  due  to  a  defect  of 
development,  the  nature  of  which  is  not  yet  known.  The  popular 
idea  of  maternal  impression  has  no  basis  except  fancy.  They  have 
distinct  relations  with  the  lines  of  embryonic  clefts. 

The  simplest  foi'm  of  nsevus  is  a  dilatation  of  the  capillaries  of 
the  corium.  When  it  extends,  it  often  reaches  the  subcutaneous 
tissue.  An  association  of  cutaneous  and  subcutaneous  angioma  is, 
therefore,  not  rare  (Fig.  81).  Conversely,  the  cutaneous  angioma 
sometimes  develops  when  the  deeper  growth  appears  under  the  skin. 

Clinically,  the  superficial  flat  ntevus  appears  as  a  bright  red  or 
dark  patch,  situated  on  the  lips,  cheeks,  face,  neck,  in  the  region  of 
the  fetal  clefts.  It  is  present  at  birth  or  appears  soon  after.  The 
margin  of  the  ntevus  is  sharp,  but  sometimes  modified  by  secondarily 
developed  smaller  n^evi.  In  area,  it  goes  from  a  pin  head  to  half 
the  face  (Fig.  76)  or  even  more.  In  such  large  n»vi  the  edges  are 
jagged  and  show  fine  ramifying  vessels.  The  coloration  of  the  skin 
varies  in  points,  and  there  are  usually  different  tints  in  the  same 
nsevus.  It  is  often  dark  purple  in  the  center  and  bright  red  at  the 
periphery.  It  is  often  broken  up  by  normal  skin,  wliich  gives  a 
variegated  appearance. 

103 


In  nnollior  tyjio  (Fig.  75)  we  find  a  raised  f^rowtli  witli  a  well- 
defined  Imrdcr.  Tlir  (.vcrlyin<r  skin  is  tliin  and  adherent  and  of  a 
reddish-hhie  color.  The  ed.ijes  are  dark-red  and  often  bordered  by 
an  areola  of  (ino  raiiiifyini;'  vessels.  The  tumor  i.s  .soft,  spongA-, 
somewhat  coniiin'ssililc,  ;uiil  liccly  movable  over  the  underlying 
structures.  'I'liis  is  llie  finiii  that  most  resembles  the  so-called 
"plexiform  angioma,"  already  referred  to. 

I\rore  oxtonsivo  growths  may  form  large,  nodular,  lobulated 
tumors,  Avhicli,  when  situalcil  in  the  oi'liil,  may  be  dangerous  from 
•extension  to  the  brain ;  but  this  is  purely  mechanical,  as  are  all  the 
destructive  effects  of  growing  cavernous  angiomata,  and  not  due  to- 
any  malignancy  of  the  growth. 

Involution  of  flat  and  hypertrophic  angiomata  has  been  observed 
as  the  result  of  inflammation,  generally  accompanied  by  ulceration. 
Nasvi  cause  no  trouble  apart  from  the  disfigurement,  when  situ- 
ated on  an  exposed  part  of  the  body. 

Cavernous  angiomata  occur  most  frequently  in  the  skin  and  sub- 
cutaneous tissue,  where  their  purple  color  and  lobulated  surface 
make  them  somewhat  resemble  a  mulberry.  They  are  often  combined 
with  simple  angioma  or  with  telangiectases.  They  also  occur  in 
muscles  and  bones,  and  in  the  brain,  breast,  liver  and  tongue  (see- 
Fig.  36). 

In  cutaneous  angioma  the  skin  is  much  thinned  and  apjiears 
lobulated  and  of  a  bluish-black  color.  In  subcutaneous  angioma  the 
skin  may  be  unaltered  at  first,  or  slightly  irregular  and  marked 
by  telangiectases.  Afterward  the  skin  becomes  thinned  or  destroyed 
by  pressure  of  the  subcutaneous  growth,  and  assumes  various  colors- 
(Fig.  80). 

In  the  face,  combinations  of  cutaneous  and  subcutaneous  angio- 
mata sometimes  form  a  characteristic  ajipearance,  the  subcutaneou.sr 
growth  giving  a  blue  color  to  the  skin,  while  the  cutaneous  angioma 
appears  in  the  form  of  lobulated  growths  or  of  bluish-red  nodules 
projecting  from  the  surface.  In  Fig.  81  the  difference  in  color  be- 
tween the  cutaneous  and  subcutaneous  angioma  is  very  mnrkcil,  th(» 
former  being  red,  the  latter  bluish  in  color. 

Subcutaneous  cavernoma  of  the  scalp  requires  special  mention^ 
as  it  may  comnuinicate  with  a  dural  sinus  through  the  emissaiy 
vessels,  without  the  scalp  showing  niucli  change. 


103 


Compression  with  a  pad,  or  by  painting  the  surface  with  collodion, 
may  sometimes  favor  spontaneous  involution  of  small  nsevi.  Excision 
is  feasible  in  nsevi  if  not  too  extensive.  It  was  performed  in  the 
case  of  Fig.  75. 

Electrolysis  is  a  good  method.  The  naBvus  is  replaced  by  a  super- 
ficial sear.  Many  sittings  are  necessary,  as  only  a  small  surface  can 
be  treated  at  a  time.  In  raised  nasvi,  electrolysis  may  cause  throm- 
bosis and  embolism. 

Cautious  cauterization  with  nitric  or  carbolic  acid  achieves  the 
same  result.    Great  care  is  needed  when  working  near  the  eyelids. 

Freezing  with  carbon  dioxide  snoiv  (Pusey)  is  the  method  now 
most  in  vogue  with  American  dermatologists.  It  gives  the  best 
results  and  is  even  supei'ior  to  radium  or  X-rays. 

Telangiectases  are  very  Avell  treated  by  electrolysis  or  cauteriza- 
tions with  carbolic  acid  after  scarification. 

For  the  treatment  of  cavernous  angioma  see  Fig.  36  and  page  48. 


Fig.  77  shows  a  subconjunctival  and  subcutaneous  ecchy- 

mosis  and  a  large  hematoma  of  the  left  side  of  the  forehead  in  a 
child,  aged  6.  The  interest  of  the  case  lies  in  the  fact  that  those  were 
spontaneous  hemorrhages  in  a  hemophiliac  individual.  The  effu- 
sion on  the  forehead  occurred  intermittently  for  a  time  and  gradually 
subsided.    There  were  no  other  hemorrhagic  foci  in  the  body. 

Hemophilia  is  a  congenital  tendency  to  hemorrhages,  either  spon- 
taneous, or  under  the  slightest  traumatic  provocation.  It  presents 
a  very  striking  example  of  hereditary  transmission.  There  are  defi- 
nite families  of  bleeders.  As  a  rule  only  the  male  descendants  are 
bleeders,  but  the  hereditary  tendency  is  transmitted  solely  through 
the  female  line. 

The  real  cause  of  hemophilia  is  unknown.  The  only  demonstrable 
alteration  of  the  blood  is  a  markedly  decreased  coagidability,  which 
has  been  explained  by  an  anomaly  of  the  vascular  cells,  blood  cells 
and  vascular  endothelium  (Sahli),  by  a  deficiency  in  thrombokinase, 
by  an  excess  of  antithrombin  (Weil),  by  an  inherited  anomaly  of  the 
construction  of  the  prothrombin  of  the  body,  evidenced  by  an  undue 
slowness  in  its  activation  (Addis) ;  which  latter  explanation  seems, 
up  to  date,  the  one  giving  the  best  account  of  the  symptoms  of  the 
disease.  Maybe,  in  some  cases,  there  is  an  abnormal  friability  of 
capillaries. 

104 


Bocki'iilicimcr,  Atlas. 


Tab.  I.IX. 


IvVhnian  Comp.Tiiy,  Niw-Vork. 


d 


But,  wluitevoi-  tlio  oanso,  tliere  occur,  either  spontaneously  or 
after  trifling  injuries  (contusion,  cuts,  tootli  extraction),  uncon- 
trollable, repeated  lieniorrlia.nos,  either  in  tlic  skin  or  sulicutaneous 
tissue,  or  externally,  or  internally. 

Of  the  external  hemorrhages,  epistaxis  is  liy  f.ir  tlie  most  frequent. 
In  the  few  female  bleeders  known,  menstruation  did  not  seem  to 
cause  as  much  hemorrhage  as  might  have  been  feared,  but  often  there 
■was  considerable  anemia. 

Needle  pricks  through  the  skin  (preferably  with  a  round  needle, 
or  venous  puncture)  do  not  give  rise  to  much  hemorrhage  in  bleeders, 
because  the  elasticity  of  the  tissues  obliterates  the  puncture.  So  that 
we  call  take  blood  specimens  for  examination  without  fear.  Intra- 
venous injection  is  preferable  to  sul)cutancous,  which  almost  invari- 
ably is  followed  by  a  hematoma. 

Subcutaneous  hemorrhages  give  the  aiipearance  shown  in  Fig.  77. 

An  interesting  condition  in  hemophilia  is  spontaneous  heiiiar- 
throsis,  which  is  recog-nized  bj^  the  "snowball  crunching"  of  the  clots 
and  hemorrhagic  infiltration  of  the  skin.  The  effusions  at  first  in- 
crease intermittently,  and  later  on  become  stationary.  From  the 
deposit  of  fibrin  on  the  articular  ends  of  the  bone,  the  cartilages  may 
be  extensively  destroyed,  with  resulting  anchylosis  in  a  tlexed  posi- 
tion, or  subluxation.  However,  sometimes,  resfitufio  ad  'vitegruni 
has  been  seen.     The  knee  is  the  joint  chiefly  affected. 

Renal  hemophilia  is  rare,  but  exists.  Formerly  many  of  the  cases 
of  hematuria  without  discoverable  cause  wej-e  called  essential  or 
hemophiliac.  Progress  of  kidney  exploration  has  considerably  re- 
stricted the  number  of  those  cases.  The  hematuria  is  profuse,  conies 
on  irregularly,  and  stop  also  without  apparent  reason.  It  causes 
marked  anemia. 

Trcd  t  m  en  t 

The  anamnesis  and  knowledge  of  the  bleeding  diathesis  in  the 

family  are  of  capital  importance  in  all  cases  of  hemophilia,    (lener- 
ally  the  patients  volunteer  the  information,  even  before  it  is  asked  for. 

Scurvy  occurs  only  under  special  conditions,  is  accompanied  by 
fever  and  ulcerations  of  the  gums;  no  liemorrhagos  occur  under  the 
skin,  in  the  joints  and  internal  organs. 

PnrpiDd  may  be  dillirult  to  diagnose  except  by  the  autcccilcut 
history. 

Barhtiv's  disease  occurs  only  in  children,  and  is  associated  with 
subperiosteal  hemorrhages,  which  can  be  felt  as  thickenings  or 
tuinoi's  near  the  cpiiihyseal  regions. 

105 


Leukcemic  hemorrhages  are  recognized  by  the  changes  in  the  blood 
and  spleen. 

Hemophiliac  hemarthrosis  is  very  characteristic.  If  any  doubt 
should  arise  between  this  condition  and  a  myeloid  sarcoma  involving 
the  joint,  X-ray  examination  would  clear  up  the  doubt. 

Treatment 

Besides  local  measures,  there  is  only  one  treatment  of  hemophiliac 
hemorrhages :  the  injection,  either  subcutaneously  or  intravenously, 
of  10  to  20  c.c.  of  fresh  human  serum,  gathered  aseptically  {Weil, 
Welch).  If  no  fresh  serum  can  be  had,  horse  or  rabbit  serum,  or 
diphtheria  antitoxin  may  be  used.  The  injection  of  10  c.c.  of  a  5% 
solution  of  peptone  of  Witte  in  saline  solution  is  also  good. 

Locally,  dusting  the  wound  with  thrombokinase  is  frequently 
efficient. 


Fig.  78  shows  a  subcutaneous  hematoma  with  large  ecchy- 
moses,  the  result  of  a  gunshot  injury  of  the  arm.  There  are  present 
all  the  well-known  discolorations  of  the  skin  in  such  cases:  purple, 
brownish-red,  green  and  yellow. 

As  is  the  rule  with  modern  projectiles  of  great  penetrating  power, 
the  aperture  of  entry,  which  is  surrounded  by  radiating  fissures,  is 
smaller  than  that  of  exit,  which  has  irregular  everted  borders.  More- 
over, the  skin  is  black  and  is  studded  with  inlaid  powder  grains, 
owing  to  the  shot  having  been  fired  at  close  range  (a  fact  of  great 
medico-legal  importance). 


The  treatment  of  giinshot  wounds  is  nowadays  as  conservative  as 
can  he.  Immediate  probing  of  the  wound  to  locate  and  extract  at 
once  the  bullet  is  no  longer  the  rule.  A  bullet  in  the  body  has  little 
importance  in  itself :  the  damage  it  has  caused  on  its  passage  is  what 
counts. 

There  may  be  an  injury  to  a  highly  vascular  organ  (spleen,  liver) 
or  to  a  big  blood-vessel:  hemorrhage  then  commands  immediate  in- 
terference. There  may  be  perforation  of  one  of  the  hollow  viscera 
of  the  abdomen:  the  ignorance  of  what  injury  has  been  produced 
and  the  fear  of  hemorrhage  and  peritonitis  make  immediate  laparo- 
tomy imperative  in  all  cases.  Of  course,  wounds  of  the  heai't  call 
for  operation  without  the  slightest  delay.    Wounds  of  the  lungs  give 

106 


I'ockciilR-iiiier,  Atlas 


Tab.  L.\. 


Robitian  Company,  New- York. 


Bockenheimer,  Atlas. 


Fig.  79.    I'elcchiae  et  I  lacmorrliagiae  per  coiiipressionem. 


Rebinan  Company,  New- York. 


Bockenheimer,  Atlas. 


Tab.  LXII. 


Fig.  80.    Haemancrioma  cavernosum  subcutaneum. 


Rebman  Company,  New-York. 


less  form.il  iii.lic-itii.ns;  miiiiy  Im.,-iI  witliont  In.ulili-.  Hemorrhage 
is  still  hero  lln'  ^■\\\^^^  imlic-ilion  Inr  opci-alioii. 

Gunsliot  injuries  of  the  skull  iuiil  l)r<iin  call  Inr  immciliato  opera- 
tion wlien  there  are  prcssiin:  syiuptoius  due  to  hemorrhage  or 
fracture). 

But  ft'unshot  wouiuLs  of  sol't  pails,  with  or  without  Itoue  sliatter- 
ing,  and  not  affecting  any  vital  organ,  are  best  left  alone,  after  thor- 
ough disinfection  of  the  orifices  of  entry  and  exit.  Especially  is  this 
true  of  battlefield  surgery,  where  the  emergency  treatment  will  solely 
be  a  generous  swabbing  of  tlie  surrounding  skin  with  tincture  of 
iodine,  and  the  application  of  an  ajjpropriate  dressing.  If  later 
infection  sets  up  in  the  wound,  it  will  be  treated  according  to  accepted 
principles.  The  bullet  will  be  located  by  the  X-rays ;  if  in  a  position 
where  it  will  cause  no  troulile,  it  is  best  to  leave  it  alone,  unless  it  be 
quite  superficial  and  easy  to  extract.  The  bullet  itself  rarely  causes 
infection,  and  generally  becomes  encysted  in  the  tissues.  Shreds  of 
cloth  carried  into  the  tissues  by  the  bullet  are  more  liable  to  cause 
septic  complications.  Bone  and  nerve  injuries  give  special  indica- 
tions, but  none  that  would  require  immediate  interference  at  the  time 
of  the  accident. 

Tetanus  is  a  possible  contingency  of  all  gunshot  wounds  and  of 
those  due  to  explosion  of  blank  cartridges  and  fireworks.  A  thorough 
disinfection  of  the  wound  with  hydrogen  peroxide  and  a  preventive 
injection  of  tetanus  antitoxin  are  elementary  rules  of  caution. 


Fig.  79  shows  a  ease  of  congestive  hemorrhage  due  to  compression 
of  the  thorax  in  a  rolling  mill,  a  case  of  so-called  traumatic 
asphyxia. 

Hemorrhage  from  compression  of  the  lower  parts  of  the  body 
generally  occurs  in  the  thorax:  compression  of  the  thorax  (crushing 
by  wheels,  machinery  accidents)  or  of  the  abdomen  causes  a  reflux  of 
blood  in  the  valveless  veins  of  the  neck,  and  the  result  is  the  very 
striking  appearance  shown  in  Fig.  79, 

The  whole  of  the  face  is  colored  dark  ]-)urple,  the  nuicosii?  of  the 
lips  and  nostrils  are  swollen,  and  there  is  also  a  subconjunctival 
ecchymosis.  (Such  ecchymoses  sometimes  occur  after  death  by 
abdominal  compression  without  visceral  lesions,  hence  their  medico- 
legal value.)  In  the  neck  there  are  petechia}  and  ecchymoses,  forming 
stripes:  there  were  also  some  ecchymoses  in  the  auditory  canal  and. 

lor 


the  drum  membrane.    As  usual  in  those  cases,  there  was  no  intra- 
cranial hemorrhage  and  the  ocular  fundus  was  normal. 

All  these  symptoms  disappeared  in  a  few  days  under  the  influ- 
ence of  rest  in  bed,  the  only  treatment  required  in  such  cases,  unless 
the  causal  compression  has  brought  about  lesions  of  internal  organs. 


Fig.  82  shows  a  case  in  which  there  was  a  visibly  pulsating  swell- 
ing in  the  region  of  the  right  sterno-clavicular  joint  in  a  middle-aged 
man,  with  a  probable  history  of  syphilis.  From  the  pulsation,  diminu- 
tion on  pressure,  systolic  bruit  and  buzzing  over  the  swelling,  the 
diagnosis  of  arterial  aneurysm  was  made ;  and  S-rays  showed  the 
tumor — which  increased  in  size  slowly,  but  continually — to  be  an 
aneurysm  of  the  aortic  arch.  There  was  a  pressure  paralysis  of  the 
recurrent  nerve,  pressure  symptoms  on  the  brachial  plexus,  and  on 
the  veins:  while  dysphagia  (pressure  on  the  esophagus)  and  dyspnea 
(pressure  on  the  bronchi  and  lung)  were  absent. 

Arterial  aneurysms  are  partial  dilatations  of  arteries.  True 
aneurysms  are  those  formed  by  all  arterial  coats.  Blaise  aneurysms 
are  only  pulsating  hematomata  due  to  an  extravasation  of  blood  out- 
side of  an  injured  artery;  they  are  fairly  frequent  complications  of 
grmshot  and  stab  wounds  of  arteries,  or  develop  after  rupture  of  a 
true  aneurysm. 

True  aneurysms  are  caused  by  disease  of  the  arterial  wall,  chiefly 
of  syphilitic  origin.'  In  generalized  arteritis,  they  may  be  multiple. 
More  usually  they  are  single  and  their  location  is  governed  by  ana- 
tomical conditions :  in  the  aorta  where  the  rebound  of  systolic  impulse 
is  more  directly  felt  than  anj^where  else ;  in  places  where  the  arteries 
are  submitted  to  traction  or  pressure  (popliteal  artery,  femoral  artery 
in  case  of  "rider's  bone,"  an  osteoma  developed  in  the  adductor 
muscles  near  Hunter's  canal,  etc.). 

Anatomically  aneurysms  are  circumscribed  or  diffuse:  when  cir- 
cumscribed they  are  cylindrical,  fusiform,  or  sacciform.  The  ana- 
tomical variety  is  important  for  the  operative  treatment. 

From  the  clinical  standpoint,  aneurysm  may  be  defined  as  a 
tumor  belonging  to  the  arterial  system;  that  is,  because  it  belongs 
to  the  arterial  system,  it  gives  certain  characteristic  physical  signs; 
because  it  is  {clinically  only)  a  tumor,  it  gives  pressure  symptoms. 

The  former  are :  1st.  ptdsation,  synchronous  with  the  heart  beat, 
increased  by  compression  of  the  artery  between  the  tumor  and  the 
peripheral  parts,  and  stopped  by  compression  of  the  artery  on  the 

108 


IJockculK'iiiicr,  Atlas. 


Tab.  LXIII. 


I-'io-.  SI.    Hainanyioina  cutaneum  ct  subcutaiicum  —  Tcleaiigiektasiae. 


Rcbinan  Company,  New-York. 


Bockenheimer,  Atlas. 


Tab.  LXIV. 


Fig.  82.    Aneurysma  arteriale. 


Rebmaii  Company,  New-York. 


side  next  the  heart,  this  latter  charafter  beiiip;  of  course  demonstrable 
only  in  ease  of  aneurysms  of  the  neck  and  liml)s;  2d.  a  bruit  on  aus- 
cultation, or  a  tlirill,  also  synchronous  with  the  systole  of  the  heart. 

Pressure  symptoms  are  particularly  marked  in  intratlioracic 
aneurysm,  th;it  is,  aneurysm  of  the  aorta,  arch  and  descendinj^  jtor- 
tion,  and  aneurysms  of  the  base  of  the  neck.  Pressure  on  the  big 
venous  trunks  causes  cyanosis  and  edema  of  the  face,  neck  and  upper 
limb;  pressure  on  the  esophagus,  dysphagia  (for  which  bougies  are 
sometimes  passed  with  fatal  results) ;  pressure  on  the  brachial 
plexus  produces  paresthesia  in  the  arm;  pressure  on  the  recurrent 
nerve  (particularly  the  left,  on  account  of  its  anatomical  position), 
paralysis  of  said  nerve,  with  characteristic  hoarseness,  unless  there 
be  compensation,  in  which  case  it  can  only  be  detected  by  laryngo- 
seopie  examination.  An  early  symptom  of  aortic  aneurysm  is 
tracheal  tug,  i.e.,  a  sensation  of  traction  from  below  when  the  larynx 
is  pulled  upward. 

When  the  attention  is  drawn  to  the  mediastinum  l)y  one  or  several 
of  those  pressure  symptoms,  which  develop  only  slowly  and  gradually 
as  the  sac  itself,  an  X-ray  examination  is  necessary.  Fluoroscopy 
will  show  a  pulsating  swelling  otherwise  indeteetable,  and  a  Wasser- 
mann  reaction  must  be  taken  to  find  out  whether  there  is  still  an  active 
syphilitic  process. 

In  aneurysms  of  the  limbs,  the  pressure  symptoms  are  evidenced 
by  edema,  trophic  and  sensory  disturhauce's,  decrease  of  the  muscu- 
lar pou-er,  ulcers,  etc.  A  large  aneurysm  may  cause  pressure  atrophy 
of  the  neighboring  bones  (sternum,  vertebrae). 

Diagnosis 

Abscesses,  or  benign  and  malignant  tumors,  especially  sar- 
coma, when  they  receive  pulsation  from  au  underlying  vessel,  may  be 
mistaken  for  aneurysm. 

Conversely,  aneurysms  in  which  there  is  no  pulsation  or  bruit, 
owing  to  thickening  of  their  walls  from  thrombosis,  and  wliidi  have 
caused  inflammatory  changes  in  the  skin  by  pressure,  may  be  mis- 
taken for  abscesses?  and  incised. 

In  cavernoma  there  is  dilatation  of  the  vessels,  lint  no  pulsation. 
Eacemose  a)ienrysm  presents  itself  as  an  irregular  serpentine  arterial 
swelling  caused  by  the  tortuous  dilatation  of  a  vascular  area. 

Aneurysm  of  the  aorta  is  frequently  difficult  to  distinguish  from 
gumma  or  syphilitic  sclerosis  of  the  mediastinum,  all  the  more  be- 
cause close  causal  relations  exist  between  those  three  conditions. 

100 


X-rays  are  very  helpful  in  the  diagnosis  of  internal  aneurysm 
because  they  show  the  outline  of  the  pulsating  tumor. 


As  a  rule,  aneurysms  have  a  slow,  but  persistent  growth  and 
eventually  tend  to  rupture.  Therefore,  the  prognosis,  generally 
speaking,  is  unfavorable,  but  m.uch  depends  on  the  condition  of  the 
arterial  ivall.  If  only  the  dilated  segTnent  is  diseased,  a  cure  may  be 
obtained  if  this  segment  can  be  buttressed  by  good  and  solid  clot 
(thoracic  aneurysms)  or  an  operation  may  be  performed  with  good 
success ;  but  if  all  of  the  arterial  system  be  diseased,  reinforcing  one 
point  will  be  of  little  or  no  avail,  since  neighboring  points  are  ready 
to  yield  before  the  arterial  pressure. 

In  aneurysms  of  the  limbs,  all  depends  on  the  efficiency  of  the 
collateral  circulation.  Several  tests  have  been  devised  for  this  pur- 
pose and  must  be  performed  before  a  final  decision  is  taken  as  to  the 
treatment. 

The  treatment  of  aneurysm  has  been  considerably  improved  of 
late  owing  to  the  tremendous  impetus  given  in  late  years  to  vascular 
surgery,  and  a  better  understanding  of  the  underlying  causes  of 
aneurysm. 

The  growing,  and  seemingly  well  founded,  belief  that  most 
aneurysms  are  traceable  to  antecedent  syphilis,  and  in  some  cases, 
due  to  an  active  direct  syphilitic  process,  indicates  the  use  of  anti- 
syphilitic  treatment,  particularly  in  aneurysms  of  the  chest.  How- 
ever, this  treatment  cannot  include  salvarsan,  for  which  well- 
developed  aneurysm  is  a  formal  contraindication. 

The  other  methods  of  general  treatment,  formerly  much  in  vogue, 
are  practically  discarded.  Injections  of  gelatinized  serum  alone 
might  sometimes  prove  serviceable  in  some  early  cases  of  thoracic 
aneurysm. 

Surgery  claims  the  treatment  of  all  aneurysms  of  the  limbs.  It 
has  not  yet  succeeded  in  curing  those  of  the  aorta,  but  the  experi- 
mental attempts  of  Carrel  and  Matas'  work  seem  to  justify  the  hope 
that  it  is  only  a  question  of  time.  Aneurysms  of  the  abdominal  aorta 
are  certainly  amenable  to  endoaneurysmorrhaphy  (Gibbon). 

Simple  ligation  of  the  artery  on  the  side  of  the  aneurysm  next 
the  heart  is  no  longer  practiced.  Ligation  distal  to  the  aneurysm  is 
still  the  only  operation  feasible  in  aneurysms  of  the  innominate 
artery  or  of  the  first  portion  of  the  carotid  and  subclavian  arteries. 
Ligation  on  both  sides  and  extirpation  of  the  sac  is  the  method  still 

110 


Bockenheinier,  Atlas. 


Tab.  LXV. 


Fig.  83.    Varix  cirsoides  —  Pes  valgus. 


Rebman  Company,  New- York. 


most  in  favor  on  the  Continent,  and  its  results  are  satisfactory. 
Extirpation  folloived  by  restoration  of  the  blood  stream  by  suture 
of  tlie  vessel  or  transplantation  of  a  piece  of  another  vessel  is  cer- 
tainly the  ideal  method  theoretically,  but  practically  it  is  too  dilFicult, 
and  the  same  results  may  he  obtained  with  much  less  troul)le  with 
endoaneurysmorrhaphy,  which  is  the  method  of  choice:  exposure 
of  the  sac,  'Dtvishni,  closure  by  suture  of  the  collaterals;  and  then 
restoration  (sacciform  aneurysm)  reconstruction  or  obliteration 
(fusiform  aneurysm)  of  the  arterial  channel.  The  Matas  operation 
disturbs  the  collateral  circulation  much  less  than  any  other  technique, 
and  gives  a  minimal  risk  of  gangTene:  it  is  not  a  particularly  difficult 
operation.  The  obliterative  type,  the  one  most  fi'equently  indicated, 
is  "ridiculously"  simple  and  easy  (Binnie). 

For  aneurysms  which  still  remain  inoperable,  such  as  those  of  the 
aorta,  wiring  {Finney,  Hare,  Lusk)  with  electropuncture  relieves  the 
pain  and  may  prolong  life.    It  is  not  a  dangerous  procedure. 

For  those  arteries  in  which  obliteration  would  be  technically  prac- 
ticable, but  would  endanger  the  supplied  territory  (common  carotid, 
abdominal  aorta)  Tlalsted's  and  Matas'  method  of  progi-essive  occlu- 
sion by  metallic  bauds  offers  a  good  way  of  testing,  and  promoting 
the  development  of  collateral  circulation. 


Fig.  83  shows  well-developed  varices  of  the  leg  in  a  woman  of  40, 
who  had  had  many  pregnancies.  As  usual,  the  territory  of  the  great 
saphenous  vein  is  most  affected.  The  dilated  veins  are  seen  as 
tortuous,  ramifying  blue  cords  under  the  thinned  skin.  Where  the 
veins  have  valves,  nodular  swellings  are  visible.  The  skin  has  a 
reddish-brown  appearance,  due  to  a  network  of  very  fine  dilated 
veins  between  the  larger  trunks. 

Varices  are  most  common  in  the  leg,  in  tall  individuals  and  in 
those  who  are  compelled  by  their  profession  to  stand  long  on  their 
feet.  Any  pelvic  tumor  obstructing  circulation  increases  the  dila- 
tation. Thus  is  explained  the  influence  of  pregnancy.  Varices  also 
occur  in  the  hemorrhoidal  (hemorrhoids.  Fig.  51)  and  spermatic 
(varicocele)  plexuses.  Also  at  the  lower  end  of  the  esopha.srus.  They 
are  very  rare  on  the  upper  limbs,  where  they  deveIo]i  only  in  con- 
junction with  tumors  blocking  the  circulation. 

Varicose  veins  are  not  only  dilated,  but  also  markedly  altered  and 
sclerotic,  which  explains  why  they  remain  gaping  when  cut;  hence 
the  copious,  sometimes  fatal,  hemorrhages  that  occur  from  apparently 

111 


unimportant  venous  twigs.  (Hematemesis  in  case  of  esophageal 
varices,  death  after  rupture  of  a  varix  of  the  leg.) 

Varices  particularly  appear  in  individuals  having  a  poor  muscu- 
lar development.  Though  causing  no  immediate  danger,  they  ar& 
responsible  for  a  number  of  unpleasant  and  painful  symptoms. 

The  patients  suifer  more  when  standing  than  when  walking.  The 
chief  symptoms  are  a  sensation  of  heaviness  of  the  limb,  tingling  and 
inumbness,  cramps  in  the  calves,  especially  when  the  deeper  veins  are 
affected;  swelling  of  the  feet  after  walking,  disappearing  after  rest 
in  bed.    All  this  results  in  more  or  less  disability. 

Frequent  complications  are  eczema,  ulcer  and  elephantiasis  (see 
Fig.  71).  Besides,  varices  may  be  dangerous  from  rtipture  and 
hemorrhage.  As  a  rule  the  small,  thin,  ramifying  peripheral  vessels 
rupture,  sometimes  the  larger  trunks.  The  blood  being  under  con- 
siderable pressure,  spurts  out  in  a  jet.  Fatal  hemorrhage  may  take 
place  unless  the  limb  is  elevated  and  the  bleeding  stopped  by  pres- 
sure. Death  may  occur  in  rupture  of  subcutaneous  varices  in  the 
leg  and  in  the  internal  organs  (e.g.  brain  and  liver). 

Another  danger  is  thromho-phlebitis,  an  example  of  which  is  rep- 
resented in  Fig.  84. 

Aseptic  thrombosis  is  a  frequent  eventuality  in  varices.  Hard 
lumps  are  then  felt  in  the  veins  under  the  skin.  Sometimes  the 
thrombi  are  calcified  and  are  then  known  as  phleboliths. 

Diagnosis 

Varices  are  easily  recognized.  The  only  possible  mistake  would 
be  to  take  for  varices  collateral  venous  circulation  developed  over  a 
tumor  (see  Fig.  32,  sarcoma)  or  over  a  deep  inflammation.  But  this 
cannot  withstand  a  serious  examination. 

An  important  point,  however,  is  to  recog-nize  the  insufficiency  of 
the  valves  of  the  great  saphenous  vein.  To  demonstrate  this,  raise 
the  limb  till  the  varices  have  emptied  themselves  of  blood ;  then  com- 
press the  saphenous  vein  at  its  opening  into  the  femoral  vein  in  the 
thigh,  lower  the  limb  and  suddenly  remove  pressure  on  the  saphenous 
vein;  the  varices  then  become  again  immediately  filled  from  above 
downward  with  blood  from  the  femoral  vein. 


Prophylactic  treatment  consists  in  avoiding  long  standing,  in 
cleanliness  and  massage.  If  the  varix  is  caused  by  pressure  of  a 
tumor,  this  must  be  removed  when  possible. 

112 


Ikxkeiiheiiner,  Atlas. 


lab.  I.XVI. 


1  iy.  81.     riirimibophlcbitis  |iuriilLiHa  aciiia. 


Kclinian  Conip.iiiy,  Nc'\v-\'iiik. 


In  sli.<j:lit  cases  tlio  circulation  i>t'  the  liinh  can  he  iin|»roveil  and 
the  ]);itient  made  (luitc  c-onit'ortalile  liy  tlie  application  of  flannel 
bandages  from  the  toes  upward  {Murtiii's  ruiiiier  bandage  is  liable 
to  cause  eczema)  or  Ity  tlie  wearing  (when  not  in  bed)  of  well-made 
elastic  stockings. 

Surgical  treatment  is  called  for  when  the  varices  keep  growing, 
circulatory  disturbances  art-  vciy  marked,  valvules  iusutlicient  and 
the  nutrition  of  the  limb  seriously  impaired  (ulcers,  etc.)- 

Simple  ligation  of  the  saphenous  vein  is  useless;  the  most  radical 
operation  is  removal  of  the  whole  saphenous  vein  through  a  uuml)er 
of  incisions,  each  segment  of  the  vein  being  pulled  out  through  the 
incision  immediately  above.  Partial  resection  of  the  vein  is  some- 
times sufficient.  Elastic  bandages  should  be  worn  for  some  time  after 
the  operation.  Extirpation  of  secondaiy  varices  due  to  thrombosis 
of  the  deeper  veins  is  useless. 

Fig.  83  also  shows  a  flat  foot,  a  condition  frequently  associated 
with  varices,  either  because  both  depend  on  a  congenital  dystrophy 
of  the  tissues,  or  because  the  falling  of  the  arch  of  the  foot  entails 
poor  circulatory  condition  and  venous  stasis  in  the  lower  limb. 


113 


INFECTIONS 

Figs.  84-131 


I.— Acute  Pyogenic  Processes— Figs.  84-114 

II.— Chronic  Infections— Figs.  115-131 

A.— Actinomycosis— Figs.  115-117 

B.-Syphilis-Figs.  118-123 

C. — Tuberculosis— Figs.  124-131 


PYOGENIC  INFECTIONS 

The  entriuice  of  l)actoi'iii  in  tlic  hoily  iimiicdiately  starts  a  wondei'- 
ful  defensive  process,  the  chief  ap:ents  of  which  are  tlie  leucocytes  of 
the  blood.  Metchnikoff  has  demonstrated  the  importance  of  phago- 
cytosis and  Ehrlich  has  explained  the  complicated  processes  that  lead 
to  antibody  formation  and  immunization,  by  liis  side-chain  theory. 

Clinically,  when  l)aeteria  begin  to  develop  in  a  given  point,  the 
inflammatory  reaction  which  is  tiie  outward  manifestation  of  the 
defensive  process  is  evidenced  by  four  cardinal  symptoms:  Redness, 
heat,  sivclling  and  pain.  The  first  tivo  are  due  to  the  active  hyper- 
emia, the  blood  being  called  in  greater  abundance  by  chemotaxis  to 
the  part.  The  swelling  is  due  to  the  transmigration  (diapedesis)  of 
leucocytes  through  the  walls  of  the  caj^illaries,  favored  by'  the  slowing 
of  the  blood  stream.  The  pain,  i:)ul sating  in  character  in  many  in- 
stances, is  due  to  the  increased  tension  in  the  tissues.  It  is  directly 
proportional  to  the  rigidity  of  the  tissues.  This  is  why  the  pain  is 
marked  in  dense  tissues,  while,  whei'e  the  connective  tissue  is  lax, 
there  may  be  enormous  edema  with  but  little  pain. 

The  exudation  is  at  first  serous  and  formed  exclusively  by  leuco- 
cytes and  clear  seinim;  later,  when  the  fight  between  leucocytes  and 
invading  micro-organisms  has  resulted  in  the  death  of  many  of  both, 
it  becomes  cloudy  owing  to  the  formation  of  pus  corpuscles.  A  pus 
corpuscle  is  a  leucocyte  that  has  engulfed  one  or  several  microbes  and 
has  died  from  its  victory.  It  then  becomes  a  foreign  body  and  has 
to  be  cast  off.  "When  there  are  but  few  microbes  and  but  little  pus 
is  formed,  the  latter  may  be  absorbed  by  other  phagocytes  of  the 
body,  and  no  collection  ensues.  This  termination  by  resolution  is 
the  most  favorable.  It  is  frequent  in  normal,  healthy  subjects,  in  case 
of  low  virulence  infections. 

The  pus  formation  is  a  fairly  accurate  gauge  of  the  manner  in 
which  the  defensive  process  is  successful.  Numerous  pus  cells  give 
a  creamy,  thick  jdus  and  indicate  a  successful  resistance  of  the  ana- 
tomical elements  against  infection;  the  latter  will  become  circum- 
scribed, and  the  only  result  will  be  an  abscess.  When  few  pus  cells 
are  present  after  the  septic  process  has  lasted  a  little  time,  it  means 
that  the  I'esistance  is  unsuccessful,  either  because  the  attacking  organ- 
isms are  very  virulent  or  the  doFending  leucocytes  are  weak.    When 

ii: 


sero-piirnlent  fluid  or  only  turbid  serosity  is  found  on  incision,  it 
generally  foretells  a  grave  infection,  a  diffuse  phlegmon.  If  tlie  latter 
is  not  stopped  in  its  progress,  the  result  is  the  invasion  of  the  blood 
stream :  generalized  infection,  septicemia  or  pyemia^  The  lymphatic 
channels  play  also  a  very  important  part  in  the  extension  of  infection. 

The  strength  of  the  resistance  depends  on  the  general  health  of 
the  body:  old,  feeble  and  diseased  individuals  (e.g.  diabetics)  are 
less  capable  of  combating  bacterial  invasion.  In  these  cases,  infec- 
tions that  TTould  be  trifling  in  a  normal  body  may  become  severe  or 
even  fatal. 

The  virulence  of  the  invading  microbe  depends  to  a  certain  extent 
on  its  nature :  there  is  no  pathogenic  microbe  that  cannot  form  pus : 
the  pneumococcus,  gonococcus,  colon-bacillus,  Eberth  bacillus,  pyo- 
cyaneus,  tubercle  bacillus,  are  frequent  pus  producers ;  but  the  most 
important  pyogenic  organisms,  from  the  surgical  standpoint,  are  the 
staphylococci  and  streptococci. 

Staphylococcic  infections  are  very  common  (furuncles,  carbuncles, 
osteomyelitis,  etc.)  and  generally  lead  to  circumscribed  purulent  in- 
flammations. Streptococcic  inflammations  are  generally  more  severe 
in  type,  more  diffuse,  and  may  lead  to  general  infection.  Mixed 
infections  are  not  rare,  but  there  always  is  a  predominant  microbe. 

This  first  stage  of  inflammation — pus  formation — is  destructive  in 
character,  not  only  of  leucocytes  and  microbes,  but  also  of  surround- 
ing connective  tissue  elements,  which  undergo  necrosis.  -  Necrosis  is 
not  much  marked  in  circumscribed  abscesses;  it  is  considerable  in 
diffuse  i^hlegToons,  where  most  of  the  tissues  bathed  in  the  turbid 
serosity  may  become  necrotic,  so  that  these  diffuse  processes  are 
accompanied  by  much  sloughing. 

Wlien  the  destructive  stage  has  come  to  an  end,  the  repair  process 
begins.  The  fixed  connective  tissue  cells  proliferate  and  form  granu- 
lations (in  abscesses,  the  so-called  "pyogenic"  membrane),  the  in- 
flammatory area  becomes  isolated  and  demarcated;  the  necrosed 
tissue  is  cast  off  with  the  pus,  and  the  wounds  eventually  heal  by 
scar  tissue,  which,  is  but  a  later  evolution  of  the  vascular  granula- 
tions. During  this  stage  of  reparation,  the  clinical  symptoms  grad- 
ually subside;  all  this  is  much  hastened  if  the  pus  has  been  evaciaated 
outside  the  body.  The  elimination  of  pus  is  effected  by  gradual 
involvement  of  tissues  and  rupture  in  cases  left  to  spontaneous  evo- 
lution; but  it  may  be  brought  about  much  more  quickly  by  a  free 
incision,  which  saves  all  the  time  that  would  be  required  for  the 

iGeneral  infection,  see  page  157. 

118 


spontaneous  ulceration  from  witliin  outward  of  tlie  structures  over- 
lying  the  pus,  and,  finally,  the  skin. 

Aside  fi'oiu  llic  local  symptoms  of  iiitlanimation,  enumerated 
above,  there  is  a  general  reaction  showed  by  a  more  or  less  con- 
sideraltle  rise  in  tcniperature.  The  fever  is  due  to  the  action  of 
toxalbumins  (toxins)  secreted  by  the  bacteria,  liberated  by  them  into 
the  blood  stream,  and  influencin.c:  the  thermic  centers  of  the  brain. 
Besides  these  exotoxins,  there  are  insoluble  endotoxins,  which  remain 
fixed  to  the  body  of  the  bacteria  themselves. 

Another  general  reaction  common  to  all  bacterial  infections  is 
the  increase  in  the  number  of  leucocytes  in  the  circulating  blood,  or 
IcKcocytosis.  This  is  the  response  of  liematopoietic  organs,  spleen 
and  J)one  marrow,  to  meet  the  demand  for  leucocytes  to  destroy  bac- 
teria. So  constant  is  this  leucocytosis  in  surgical  infections  that  a 
lilood  count  is  now  a  routine  procedure  in  the  examination  of  such 
cases.  The  leucocytosis  is  also,  to  a  certain  extent,  a  gauge  of  the 
intensity  of  the  defensive  pi-ocess. 


Every  pyogenic  infection,  however  slight  it  may  seem,  requires 
watchful  treatment,  because  unexpected  and  unpleasant  surprises  are 
always  possible.  Cases  are  frequent  where  an  apparently  trifling 
septic  wound  has  resulted  in  a  fatal  septicemia.  Under  ordinary 
conditions,  and  with  appropriate  treatment,  the  prognosis  is  favor- 
able in  inost  pyogenic  infections:  but,  nevertheless,  these  remain  one 
of  the  big  factors  of  post-o]ierative  mortality,  perhaps  the  biggest, 
despite  the  progress  of  surgical  technique. 

To  limit  the  infection  and  to  favor  the  natural  defensive 
process  is  the  alpha  and  omega  of  surgical  treatment  of  suppurative 
conditions. 

General  treatment  consists  in  a  substantial  diet  and  tonics.  Sera 
and  vaccines,  which  are  useful  in  chronic  conditions  and  medical 
septicemifP,  are  not — barring  a  few  exceptions — of  much  value  in  sur- 
gical acute  infections,  nor  are,  probably,  colloidal  metals  (collargol, 
electrargol,  etc.).  Nucleinic  acid  (20  c.c.  in  200  c.c.  of  saline  solution) 
has  found  favor  in  Germany. 

Local  measures'  are  rest,  dressings  and  hyperemia.  It  was  Bier 
who,  running  against  all  jirinciples  formerly  admitted,  drew  the  atten- 
tion to  the  fact  that  hyperemia  and  its  consequences,  far  from  being 

I  liiunclimi^  with  iilitliyiil  iir  tiii'iciirial  ointment,  and  iodine  preparations  may  hasten 
tlic  risdlutiiiti  i>f  :i  iiciM-=,ii|iiJiu;itivo  iiifi-ct inn,  piirticularly  adenitis.  This  is  but  one  kind  of 
hyperi'inia  treat luoiit. 

119 


harmful  and  having  to  be  restricted  and  kept  under  control,  was 
indeed  the  very  effort  of  the  organism  to  bring  about  a  cure :  hence 
his  method  of  passive  hyperemia,  which  has  been  enthusiastically 
received  by  some,  wrongly  applied  to  all  sorts  of  cases,  among  which, 
of  course,  some  where  it  was  not  indicated,  and  subsequently  con- 
demned as  worthless,  as  a  "double-edged"  sword,  as  impairing  th^ 
nutrition  and  delaying  the  absorption  of  bacteria  and  bacterial  toxins. 

Certainly  passive  hyperemia,  improperly  apijlied,  may  do  harm, 
but  this  is  no  fault  of  the  method.  Nor  is  it  just  to  decry  it,  because  it 
has  not  fulfilled  the  expectations  of  those  who  asked  of  it  what  it 
could  not  give.  Passive  hyperemia  is  not  supposed  to  take  the  place 
of  all  other  methods  of  treatment  of  pyogenic  infections;  it  is  only 
one  of  several  means,  and  one  which,  when  employed  correctly,  in 
proper  cases,  is  undoubtedly  benetieial.  However,  we  shall  add  that, 
generally  speaking,  we  have  seen  much  better  results  in  subacute  and 
chronic  than  in  acute  inflammatory  processes. 

But  the  subject  of  hyperemia  in  the  treatment  of  acute  infections 
goes  far  beyond  the  question  of  passive  hyperemia,  which  is  only  a 
particular  (and  not  the  natural)  mode.  Active  hyperemia  is  the 
natural  defensive  process,  and  many  of  our  methods  are  only 
means  of  inducing  it.  Thus  the  swabbing  of  an  infected  surface 
with  tincture  of  iodine  is  nothing  but  hyperemia ;  so  is  the  touching 
of  a  small  boil  with  carbolic  acid ;  so  is  also  the  use  of  moist,  tvarm., 
antiseptic  dressings  or  of  hot  antiseptic  baths,  one  of  the  most  efficient 
treatments  at  our  disposal.  Ice  bags  are  injurious,  though  they  may 
relieve  pain,  because  they  hiake  the  blood-vessels  contract  and  retard 
hyperemia.  Rest  favors  hyperemia  by  slackening  the  circulation. 
Elevation  of  the  limb  is  useful  only  to  r-elieve  the  pain  and  has  no 
curative  value. 

It  goes  without  saying  that  all  sources  of  irritation  (foreign 
bodies,  stones,  etc.)  must  be  removed. 

When  pus  has  formed  and  collected,  it  must  be  evacuated  by  an 
incision  sufficient  to  insure  free  drainage  and  no  retention.  For- 
merly long  incisions  were  the  only  ones  considered  as  worthy  of  the 
name  of  "surgical."  A  judicious  application  of  Bier's  method 
enables  us  to  shorten  the  incision  in  many  eases.  A  notable  instance 
is  given  by  finger  suppurations.  The  scar  retraction  shown  in 
Fig.  64  is  due  in  part  to  the  long  incision,  formerly  so  much  in  honor. 
An  infinitely  better  result  is  oljtained  nowadays  by  multiple  small 
incisions  alongside  the  tendon,  and  hyperemia  {Klapp's  method). 

The  time  for  incision  in  circumscribed  abscesses  is  when  the  pus 

120 


has  collected.  In  difTuso  processes,  it  must  l)e  niiide  witliout  delaj'v 
as  it  is  the  only  means  of  clieckiiiij  further  i)rof?ress. 

Early  incision  is  also  indicated  when  the  inflamed  tissue  is  encased 
and,  so  to  speak,  straii^uhited  in  a  touf,di  inextensihie  sliealh,  liecause 
tlie  pain  is  then  very  severe  and  incision  aiTords  a  sure  and  prdiiipt 
relief  (e.g.,  treatment  of  ei)ididymitis  hy  Hagner's  method). 

"When  liie  incision  cannot  be  done  rapidly  without  anesthesia,  or 
under  superficial  anesthesia  by  freezing,  it  is  best  to  i-esort  to  general 
narcosis,  unless  the  abscess  is  situated  in  a  part  where  regional 
(conduction)  anesthesia  is  possible;  because  local  infiltration  anes- 
thesia is  unsatisfactory  in  inflamed  and  edematous  tissues.  All 
connective  tissue  septa  within  the  abscess  cavity  must  be  broken. 
Retention  of  pus  increases  the  virulence  of  the  bacteria  and  the 
danger  of  absorption  (see  general  infection,  ])age  157).  InsulficieDt 
drainage  leads  to  fistulaj  such  as  tliat  of  Fig.  55. 

The  drainage  of  abscesses  is  done  best  with  rubber  tubes,  if  the 
discharge  is  profuse;  by  a  cigarette  drain  if  the  same  is  scanty. 

Various  dressings  can  be  applied  on  infected  wounds  or  those 
resulting  from  the  incision  of  abscesses.  A  hot  tvet  dressing  covered 
ivith  impervious  material,  such  as  oiled  silk,  is  only  a  way  of  inducing 
hyperemia,  as  already  stated,  and  belongs  to  the  early,  pre-incision,. 
stage  of  treatment.  A  wet  dressing  covered  imth  absorbent  cotton, 
but  tvithout  impervious  fabric,  dries  up  soon  and  powerfulh^ 
draws  pus  by  capillarity;  it  is  the  best  dressing  to  apply  just  after  the 
incision  when  there  is  much  pus. 

A  dry  dressing  is  the  l)est  to  promote  cicatrization:  it  is  the  kind 
to  apply  when  the  discharge  becomes  scanty.  If  it  adheres  to  the 
surface  of  the  wound,  it  must  not  be  stripjied  off  violently,  but  first 
soaked  with  hydrogen  peroxide  or  a  solution  of  sodium  perborate, 
which  makes  its  removal  easy. 

"When  no  more  discharge  exudes,  the  wound  may  be  ]iacked  with 
gauze  to  allow  it  to  close  from  the  botioin  upward.  Superficial  closure 
over  an  imperfectly  drained  cavity  leads  to  the  formation  of  sinuses 
such  as  that  represented  in  Fig.  55.  Granulation  tissue  should  be 
controlled  in  its  growth  by  fre(|Uont  applications  of  silver  nitrate. 

Innnobilization  of  the  part  must  be  continued  till  all  signs  of 
inflannnation  have  subsided.  After  healing,  massage  and  electricity 
are  indicated,  accordiii.i;'  to  the  sitiuilioii  and  nature  of  ilic  alTcetion. 


Vi\ 


Fig.  84  shows  an  acute  purulent  throtnbo-phlebitis  affecting  a 
varicosity  of  the  saphenous  vein,  which  develoijed  after  pregnancy. 
There  is  a  patch  of  diffuse  redness  with  yellowish  nodules  indi- 
cating the  development  of  abscesses  in  the  infiltrated  and  thrombosed 
vein. 

This  is  a  not  infrequent  complication  of  the  condition  shown  in 
Fig.  83  (seepage  112). 

Inflammation  of  veins,  or  phlebitis,  may  be  seen  after  many  pyo- 
genic affections  (lymphangitis,  furuncle,  carbuncle,  erysipelas,  vari- 
cose ulcer  of  the  leg).  Antecedent  pathologic  changes  of  the  venous 
walls  (varices  most  commonly)  make  them  more  liable  to  infection. 

In  some  cases  the  contamination  comes  by  contiguity  from  a 
neighboring  sujDpurative  process.  In  every  pyogenic  infection  micro- 
scopical purulent  thrombi  are  found  in  the  small  venous  radicles.  In 
larger  veins,  periphlebitis  develops  first  and  then  the  vein  itself  is 
involved :  e.g.  involvement  of  the  lateral  sinus  in  otitis  media,  of  the 
facial  vein  and  cavernous  sinus  in  furuncle  of  the  face. 

But,  more  frequently,  the  phlebitis  is  a  result  of  a  blood  in- 
fection. 

Anatomically,  phlebitis  is  invariably  accompanied  by  the  forma- 
tion of  a  thrombus,  which,  in  the  cases  now  under  consideration,  is 
always  septic.  (Aseptic  thrombosis  is  possible  after  surgical  opera- 
tions, particularly  on  the  abdomen.)  If  the  virulence  of  the  microbes 
is  not  too  great,  and  the  resistance  power  of  the  tissues  good,  the 
thrombus  does  not  go  to  pus  formation.  The  result  is  the  plastic 
form  of  phlebitis,  seen  particularly  in  the  femoral  vein  of  women  as 
the  result  of  puerperal  parametritis,  and  known  under  the  name  of 
phlegmasia  alba  dolens  (painful  white  leg),  which  describes  the  car- 
dinal symptoms  of  the  condition. 

If  the  virulence  is  great,  purulent  degeneration  of  the  thrombus 
sets  in :  the  thrombus  disintegrates  and  by  repeated  embolisms  causes 
a  general,  usually  fatal,  pyemia,  with  formation  of  multiple  abscesses. 
Thus  infection  of  the  portal  vein  gives  rise  to  pylephlebitis  and 
multiple  abscesses  of  the  liver. 

Non-suppurative  phlebitis  is  heralded  in  by  a  local  thermic 
ascension,  in  the  part  affected,  as  well  as  by  fever.  The  part  (leg 
generally)  becomes  ,s«'o??e«,  white,  painful,  so  that  motion  is  im- 
possible. The  edema  is  hard.  The  thrombosis  may  be  so  extensive 
as  to  cause  gangrene  of  the  extremities.  The  veins  are  felt  as  thick, 
hard  cords  (not  to  be  manipulated  roughly). 

Purulent  thrombo-phlebitis,  if  superficial,  gives  the  ordinary  symp- 

123 


Bockenheimer,  Atlas. 


Tab.   LXVII. 


Fig-.  85.    Abscessus  subcutaneus. 


Rebman  Company,  New-York. 


toms  of  iiiilaiiuiiatioii,  rodiies.s,  .swelling  and  edeiiui  of  llie  skin  and 
subcutaneous  tissue,  pain,  fever  and  chills.  These  last  symptoms 
are  much  more  markeci,  nTid  iiiiiy  hn  the  only  symptoms,  in  deep- 
seated  purulent  i)lil('l)itis.  A  .hi  1 1  .ilter  an  operation  for  a  septic 
condition  (otitis  media,  mastoid,  for  instance)  is  always  an  ominous 
symptom,  claiming  immediate  attention. 

In  non-fatal  eases  of  thromho-phjebitis,  resorption  of  the  throm- 
bus takes  place,  the  cells  of  the  endothelium  of  the  thrombosed  spot 
proliferating  and  invading  the  clot.  This  explains  why  there  always 
remains,  in  those  cases,  a  thickening  of  the  vein,  which  often  goes  to 
complete  occlusion.  Hence  the  post-phlebitic  chronic  congestion, 
which,  in  the  lower  extremities,  leads  to  deficient  nutrition  (ulcer, 
eczema,  elephantiasis,  equiuus  club-foot).  Thrombi  may  become 
transformed  into  hard,  painful  phleboliths,  by  deposit  of  calcareous 
salts. 

The  thrombosed  veins,  that  are  felt  as  thick,  hard  cords,  along 
the  anatomical  course  of  veins,  diflferentiate  thrombo-phlebitis  from 
lymphangitis.  "When  those  cords  cannot  be  felt,  in  deep  situated 
lesions,  the  diagnosis  of  thrombo-phlebitis  from  other  pyogenic 
infections  becomes  often  very  obscure. 

The  two  dangers  of  phlebitis  are  embolism  (hence  very  important 
and  obvious  rules  of  caution)  and  generalized  infection.  Em- 
bolism is  the  mechanism  of  generalized  infection,  but  it  has  also 
special  dangers  of  its  own. 

Treatment 

Complete  immohility  and  rest  are  essential,  and  practically  con- 
stitute all  the  treatment  of  non-suppurative  phlebitis. 

Suppurative  phlebitis  calls  for  incision:  there  need  be  no  fear  of 
hemorrhage:  thrombosed  vessels  do  not  bleed.  Ligation  proximal  to 
the  diseased  segment,  or  resection  between  ligatures,  is  indicated 
to  ward  ofif  an  impending  generalization  (jugular  vein  in  otitis 
media,  facial  vein  in  furuncle  of  the  lip,  pelvic  veins  in  puerperal 
septicemia). 

After  subsidence  of  all  symptoms,  gentle  massage  is  indicated  to 
improve  the  circulatory  conditions  in  limbs  that  have  been  the  seat 
of  thrombo-phlebitis. 


Fig.  85  shows  a  subcutaneous  abscess  surrounding  the  nipple, 
shortly  after  childbirth.  The  portal  of  entry  of  bacteria  was  a  crack 
of  the  nijiple.    The  skin  around  the  latter  is  bluish-red  and  swollen. 

123 


Fluctuation  indicates  the  presence  of  fluid  in  the  subcutaneous  tissue. 
Despite  the  apparently  slight  extent  of  the  abscess,  there  were  well- 
marked  general  symptoms.  The  abscess  healed  quickly  after  in- 
cision. 

Acute  abscesses  must  be  distiug-uislied  from  cold  abscesses,  that 
is,  from  all  purulent  collections  resulting  from  the  liquefaction  of 
infiltration  deposits  in  chronic  infections  (tuberculosis,  syphilis,  spo- 
rotrichosis, etc.).  The  rapid  evolution  and  the  cardinal  symptoms  of 
inflammation  make  this  distinction  easy. 

Siiperficial  abscesses  are  easily  detected  by  fluctuation.  The 
purulent  nature  of  deeper  collections  is  established  by  exploratory 
puncture.    Incision  and  drainage  is  the  only  treatment. 


Fig.  86  shows  another  sujipurative  condition  of  the  breast,  due 
also,  as  are  the  most  frequent  inflammations  of  that  gland,  to  the 
puerperal  state.  TMs  condition  is  of  more  moment  than  the  one 
shown  in  Fig.  85.  It  is  an  intraglandular  infection,  a  mastitis,  situ- 
ated in  the  outer  and  lower  quadrant  of  the  organ.  (This  location 
is  the  most  frequent,  owing  to  the  dependent  position  of  this  seg- 
ment and  consequent  congestion.)  ,The  inflammatory  sjTnptoms  are 
very  marked.  The  skin  is  reddened,  tense  and  infiltrated ;  the  whole 
of  the  outer  and  lower  part  of  the  mamma  is  hard  and  painful.  No 
fluctuation  anywhere.  There  were  the  usual  general  symptoms,  fever 
and  malaise,  and  radiating  pains  in  the  arm. 

In  some  cases,  purulent  mastitis  causes  an  acute  suppurative 
lymphangitis  with  involvement  of  the  axillary  glands. 

Differential  diagnosis 

Mastitis,  that  is,  abscess  of  the  breast  itself,  must  be  distinguished 
from  superRcial  abscesses  in  the  region  of  the  nipple  (Fig.  85) :  the 
latter  are  well  circumscribed  and  do  not  cause  deep  infiltration.  Also 
from  the  deep  retro-mammary  abscesses ;  there  may  be  some  un- 
certainty in  the  diagnosis  when  inflammation  of  the  mamma  exists  at 
the  same  time.  A  phlegmon  of  the  retro-mammary  bursa  raises  the 
whole  gland  from  the  thorax;  the  skin  is  iisually  intact;  palpation  of 
the  breast  causes  no  pain,  while  pressing  the  breast  against  the  thorax 
is  very  painful.  The  pus  bulges  in  the  fold  under  the  breast.  There 
is  generally  an  acute  axillary  adenitis  and  pain  on  moving  the  arm 
is  more  marked  than  in  ordinary  mastitis. 

Chronic  mastitides,  either  simple,  or  tuberculous,  or  actino- 
mycotic, or  syphilitic,  do  not  have  the  acute  course  of  puerperal 

124 


[inckciilii-imcr,  Atlas. 


Fig.  86.    Mastitis  pucrperalis  punilciitn. 


Ri'hin.iii  ("niiip.niiy,  NcwVoik. 


Bockenheimer,  Atlas. 


Tab.  LXIX. 


Rebman  Company,  New- York. 


mastitis  and  the  aiiaiiim'sis  is  difTereiit.  It  is  imicli  liarder  to  differ- 
entiate tliese  various  types  of  chronic  lesions  between  themselves 
than  from  acute  pyogenic  inflammations.  Nor  does  mastitis  neona- 
torum or  the  similar  congestive  condition  observed  at  puberty  give 
cause  to  any  confusion.  However,  it  may  sometimes  be  attended  by 
superficial  abscess  formation. 

One  form  of  acute  cancer  of  the  breast  (Fig.  15),  the  mastitis 
carcinomatosa  of  Vitllnixnni,  or  (((niiwinn  iiiaslitoides,  somewhat 
resembles  mastitis,  inasmuch  as  it  also  develops  during  tiie  lactation 
period.  However,  the  malignancy  is  so  evident  that  the  dia.gnosis  is 
easy  if  only  one  thinks  of  that  form  of  cancer,  as  one  always  sliould  do. 

Galadocelc  and  milk  abscess  have  a  special  doughy  consistency 
and  disappear  after  removal  of  the  milk  by  a  breast  pump. 

Treatment 

Treatment  of  puerperal  mastitis  is  incision  in  a  radiating  direc- 
tion. All  recesses  should  be  opened  and  connective  tissue  septa 
broken :  free  drainage  should  be  insured.  Xaturally,  the  breast  is  of 
'no  further  use  for  nursing  at  the  present  time. 

Bier's  suction  cups  are  very  useful  in  the  treatment  of  su})- 
purative  mastitis.  Aspiration  of  the  pus,  with  the  application  of 
passive  hyperemia,  often  spares  the  necessity  of  making  a  large  in- 
cision, which  will  leave  an  unsightlv  scar. 


Fig.  87  shows  a  furuncle  with  lymphangitis  in  one  of  tlie  most 
common  locations,  the  nape  of  the  neck;  Fig.  88  a  ease  of  furuncu- 
losis  in  a  young  child ;  Fig,  89  a  carbuncle  of  the  nape  of  the  neck 
in  a  man  of  40. 

All  these  lesions  are  staphylococcic  infections  of  the  pilosehaceous 
system. 

The  bacterial  invasion  occurs  through  the  duets  of  the  sebaceous 
glands.  Even  slight  friction  is  sufficient  to  cause  staphylococci, 
which  are  always  present  on  the  skin,  to  enter  the  sebaceous  ghmds, 
where  they  find  more  favorable  conditions  for  their  growth  than  on 
the  surface  of  the  skin.  In  uncleanly  jiersons  pustules  often  occur 
on  the  skin,  each  one  pierced  by  a  hair.  This  purulent  inflammation 
of  the  sebaceous  glands  is  called  folliculitis.  (In  the  eyelids  folli- 
culitis of  the  eyelashes  forms  hordeolum,  or  stye.)  Folliculitis  is 
cured  by  e])i]ation  of  the  hairs,  and  may  l)e  avoided  by  cleanliness. 

The  inflammation  may  extend  beyond  the  sebaceous  gland  and 

125 


cause  inflammatory  infiltration  of  the  skin  and  a  furuncle  (boil) 
develops.  The  pathological  process  consists  in  hyperemia  and  exuda- 
tion, with  redness  and  hard  swelling  of  the  skin,  followed  by  necrosis 
■of  the  tissue  in  the  center  of  the  infiltration;  afterward  regener5,tion 
by  the  formation  of  granulation  tissue. 

Furuncles  occur  especially  in  parts  which  are  exposed  to  irri- 
tation— the  nape  of  the  neck,  the  wrist  joint,  the  buttocks,  the  thigh 
and  the  face.  They  often  develop  secondarily  to  cracked  conditions 
of  the  skin  caused  by  eczema,  excoriations,  etc.  In  diabetics,  fur- 
uncles are  very  common  owing  to  the  dry  condition  of  the  skin  and 
the  scratching  produced  by  pruritus,  also  to  the  body  being  especially 
vulnerable  to  bacterial  invasion.  For  this  latter  reason,  carbuncles 
in  diabetics  are  still  more  common  than  furuncles.  Furuncles  may 
also  appear  in  all  cases  where  the  bodily  resistance  is  impaired — in 
children,  old  people,  and  the  tuberculous.  Then,  either  they  are  few  in 
number  or  there  is  an  outbreak  of  furuncles  over  the  whole  body, 
iurunculosis  (Fig.  88),  in  which  most  of  the  furuncles  are  not  as 
well  developed  as  when  there  are  but  a  few  of  them  (Fig.  87).  In 
furunculosis  of  children,  and  in  many  aborted  boils  of  full-grown 
people,  the  process  consists  in  the  formation  of  multiple,  small  nodu- 
lar infiltrations  in  the  skin,  in  which  there  is  no  central  necrotic  core, 
but  a  small  abscess.  This  is  seen  in  a  few  of  the  larger  boils  in 
Fig.  88. 

The  clinical  appearance  of  furuncle  is  typical.  From  a  small 
punctiform  redness  develops  a  hard,  redder,  painful  nodule  imbedded 
in  the  skin,  and  which  extends  at  its  periphery  and  also  deeply 
toward  the  fascia.  The  epidermis  is  at  first  intact,  but  afterward 
ruptures  at  the  apex  of  the  projecting  furuncle,  exposing  a  yellow- 
ish centre,  which  becomes  more  and  more  demarcated  from  the 
hard,  red  infiltration.  In  this  way  a  round,  crateriform  ulcer  is 
produced  with  a  central  yellowish  core  (Fig.  87).  Sometimes  a  hair 
is  situated  in  the  centre  of  the  furuncle. 

Large  furuncles  are  extremely  painful  owing  to  the  inextensibility 
of  the  inflamed  tissues  and  the  resulting  high  tension  in  the  central 
parts.  Motion  exaggerates  the  pain,  so  that  patients  instinctively 
immobilize  the  region  (stiff  neck  in  furuncles  of  the  nape). 

General  symptoms  are  marked  in  large  furuncles.  They  subside 
when  the  central  core  becomes  loosened  by  suppuration.  The  cavity 
is  then  quickly  filled  by  granulation  tissue,  which  may  form  a  cicatrix 
in  a  few  days.  The  hard  infiltration  remains  for  a  long  time  and 
generally  causes  unpleasant  itching  of  the  skin.    The  scar,  which  is 

12G 


Bockenheimer,  Atlas. 


Tab.  LXX. 


Fig.  8Q.    Carbunculus. 


Rebman  Company,  New- York. 


always  liypcviroiiliic  in  all  iiiflaiiniKitni'v  processes,  may  also  cause 
troulilo. 

Carbuncle  is  but  an  aKH'l"i"ii-'i'iitioii  t)L'  I'uruuck'S,  resulting  rroin  the 
iutVctiou  of  several  sebaceous  glands  and  differing  only  by  its  greater 
extent,  both  in  surface  and  doptli.  Tt  also  differs  in  being  frequently 
a  streptococcic  condition. 

The  skin  gives  way  in  several  ])laces  and  there  are  several  yellow 
cores.  Connnencing  as  a  small,  red  nodule,  it  quickly  develoi)S  into  a 
hard  infiltration,  extending  to  the  fascia,  and  may  eventually  attain 
the  size  of  a  hand,  and  cause  more  or  less  diffuse  inflammatory  infil- 
tration of  the  neighboring  jjarts.  Lymphangitis  and  adenitis  are  gen- 
erally present.  The  affection  is  accompanied  by  severe  pain,  high 
fever  and  rigors.  Furuncle  can  develop  into  carbuncle,  especially 
when  the  core  has  been  forcibly  expressed.  Carbuncle  of  the  nape  of 
the  neck  may  attain  an  enormous  size  and  spread  from  ear  to  ear.  In 
diabetics,  carbuncle  causes  extensive  necrosis  and  is  a  serious 
aft'ection. 

Complications  may  increase  the  severity  of  furuncle.  There  is 
always  lymphangitis,  especially  in  the  extremities,  and  often  lym- 
phadenitis. Early  implication  of  the  lymphatics  signifies  extensive 
inflammation  and  virulent  bacteria. 

Several  furuncles  are  sometimes  found  close  together,  either  from 
simultaneous  infection  of  several  sebaceous  glands  or  from  secondary 
infection  from  the  primary  furuncle.  This  often  occurs  after  the 
application  of  plaster  or  other  measures  with  the  object  of  "drawing 
out"  the  furuncle.  Such  cases  must  be  distinguished  from  primary 
carbuncle  (Fig.  88),  which,  as  already  said,  is  also  an  agglomeration 
of  furuncles,  but  of  a  distinct  type. 

Extensive  furunculosis  may  be  fatal  from  exhaustion.  It  may  also 
lead  to  jiurulent  thrombo-phlebitis  and  general  sepsis. 

Furuncles  of  the  lip  or  carbuncle  of  the  face  may  cause  menin- 
gitis by  thrombo-phlebitis  of  the  facial  vein  and  cavernous  sinus  and 
general  pyemia  may  be  caused  by  thrombo-phlebitis  of  the  jug-ular 
vei)!.  Renal  abscess  and  osteomyelitis  (see  page  147)  are  other 
possible  complications. 

Lymphangitis,  as  sliowii  in  Fig.  87,  appears  as  red.  dift'use 
patches,  which  soon  develop  into  irregular  red  cords  extending  from 
the  periphery  to  the  root  of  the  limb.  The  number  of  those  red  cords, 
which  are  smalh'r  than  the  cords  of  thronilio-iiliI(>bitis,  diminishes  in 

127 


the  upper  part  of  the  limb,  till  finally  there  is  only  one  reaching  the 
regional  glands,  which  are  swollen  and  tender.  The  cords  themselves 
are  slightly  raised  above  the  level  of  the  skin,  tender  on  pressure,  and 
abscesses  frequently  develop  within  and  around  them. 

Diagnosis 

The  acuminated,  localized  swelling  of  an  ordinary  furuncle  can 
hardl}^  be  mistaken  for  any  other  affection. 

Furuncles  originating  in  the  sweat  glands  are  often  described  as  a 
separate  condition  {hydradenitis  or  hidrosadenitis).  The  distinction 
has  practically  no  importance.  The  sweat  gland  furuncles  are  par- 
ticularly frequent  in  the  axilla. 

Metastatic  furuncles  are  associated  with  other  pyogenic  infections. 

Acne  is  sometimes  associated  with  furuncular  lesions,  and  might 
somewhat  resemble  furunculosis  in  its  attenuated  form.  But  the  pres- 
ence of  comedones  and  the  painlessness  of  lesions  help  settle  the 
diagnosis. 

Anthrax  (malignant  pustule)  differs  from  carbuncle  in  the  pres- 
ence of  small  vesicles  filled  with  turbid  fluid  and  early  central  necrosis 
of  the  skin,  and  in  the  absence  of  cores  (see  Figs.  112  and  113).  In 
doubtful  cases  a  bacteriological  examination  must  be  made. 


All  constitutional  disturbances  (diabetes,  anemia)  should  receive 
proper  treatment,  the  diet  should  be  invigorating,  and  the  skin  kept 
very  clean. 

Old-fashioned  poultices  are  to  be  rejected,  as  they  favor  auto- 
inoculations  in  the  neighboring  skin.  On  the  contrary,  hot  antiseptic 
dressings  are  beneficial  (hyperemia). 

Small  furuncles  may  sometimes  be  aborted  by  pulling  out  the  cen- 
tral hair  and  swabbing  the  resulting  hole  and  the  apex  of  the  furuncle 
with  pure  carbolic  acid. 

Incision  does  not  materially  shorten  the  duration  of  a  boil,  but 
markedly  decreases  the  pain.  When,  therefore,  it  becomes  likely  that 
.  a  furuncle  will  suppurate,  there  is  no  reason  to  delay  free  incision,  so 
as  to  give  complete  relief  of  tension.  This  is  done  after  careful  disin- 
fection of  the  skin,  under  local  anesthesia  for  simple  furuncles,  under 
general  anesthesia  for  carbuncles,  in  which  the  crucial  incision  must 
be  deep.  The  core  of  a  furuncle  should  never  be  forcibly  expressed. 
'The  best  way  to  hasten  healing  in  a  carbuncle  is  to  remove  all  the 
inflammatory  mass.     Protecting  the   surrounding  skin  with  fatty 

128 


Bockenheinier,  Atlas. 


Tab.  LXXI. 


Fig.  90.    Erysipelas  erytliematosum. 


Rebman  Company,  New- York. 


;mtisei)tic  ointnionts  is  j^ood.    Tlie  thermocautery  was  formerly  much 
used  iu  tlie  treatment  of  carbuncles.    It  has  no  special  advantages. 

Furunculosis  has  heen  treated  internally  with  yeast  preparations, 
and  more  recently  with  .stajiliylococcic  vaccines  (stock  or  autogenous), 
which  give  good  results  in  acne. 


Fig.  90  shows  a  typical  case  of  erysipelas  of  the  face,  which 
originated  from  a  fissure  on  the  nose. 

Erysipelas  is  tlie  stre])tococeus  infection  of  the  .skin.  The  strep- 
tococcus of  erysipelas,  formerly  thought  a  distinct  species,  is  very 
likely  the  Streptococcus  pyogoics. 

While  in  lymphangitis  the  deeper  and  larger  lymphatics  are  in- 
fected, in  erysipelas  the  smaller  lymphatic  spaces  of  the  skin  and 
subcutaneous  tissue  are  plugged  with  streptococci.  A  similar  con- 
dition may  occur  in  the  superficial  layers  of  the  mucous  membranes. 

Erysipelas  may  occur  wherever  there  is  a  solution  of  continuity 
in  the  skin — after  sci'atches  and  excoriations,  after  all  injuries  and 
operation  wounds.  Spontaneous  or  "medical"  erysipelas  is  most 
often  seen  on  the  face,  and  the  portal  of  entry  is  an  excoriation  of 
the  skin  or  of  the  nasal  mucosa.  It  generally  begins  in  the  inner 
canthus.  It  may  also  be  combined  with  various  pyogenic  affections — - 
whitlow  and  phlegTiion.  Conditions  which  give  rise  to  constant  irri- 
tation of  the  skin,  such  as  lupus,  tuberculous  fistula,  ulcer  of  the  leg, 
foreign  bodies,  etc.,  may  also  give  rise  to  erysipelas,  which  is  then 
often  relapsing.  Eelap.sing  erysii^elas  of  the  face  and  leg  may  cause 
elephantiasis,  flattening  of  the  nose  and  considerable  deformity. 
Lastly,  erysipelas  may  arise  iu  general  streptococcic  infection,  and  is 
then  always  comljined  with  other  pyogenic  conditions — abscess,  phleg- 
mon, etc. 

Some  subjects  seem  to  have  a  particular  predisposition  to  erysipe- 
las, so  that  they  will  coTitract  the  disease  whenever  exposed  to  the 
infection. 

The  common  form  of  erysipelas,  which  consists  in  a  red  elevation 
of  the  skin,  is  called  erythematous  erysipelas  (Fig.  90).  In  bullous 
erysipelas  the  skin  is  covered  with  vesicles  (Fig.  91 ).  In  hemorrhagic 
erysipelas  there  is  hemorrhage  in  the  skin  (Fig.  91).  In  the  great 
majority  of  ca.ses  erysipelas  ends  by  resolutioji,  but  sometimes  it  may 
cause  cutaneous  abscesses,  and  in  the  form  of  gangrenous,  phleg- 
monous erysipelas  may  give  rise  to  ulceration  and  extensive  destruc- 
tion of  the  skin. 

129 


The  clinical  symptoms  of  erysipelas  are  characteristic.  The  dis- 
ease usually  commences  by  a  chill,  high  temperature  (104°-106°)  and 
redness  of  the  skin.  There  is  itching  and  tension  in  the  skin,  and 
tenderness  on  pressure.  There  is  considerable  constitutional  disturb- 
ance, owing-  to  high  fever,  headache  and  vomiting,  which  continue 
while  the  disease  progresses.  The  affected  skin  is  red,  tense,  some- 
what glistening  and  slightly  raised  above  the  level  of  the  rest  of  the 
skin.  The  borders  are  well  defined,  distinctly  raised  and  zigzag  (seen 
in  Fig.  90,  especially  toward  the  scalp  and  the  neck), so  that  the  exten- 
sion of  erysipelas,  especially  on  the  face,  haS'  been  compared  to  lam- 
bent flames.  When  the  disease  spreads  over  the  whole  body,  it  is 
spoken  of  as  migratory  erysipelas.  In  places  where  the  skin  is  loosely 
attached  (eyelids,  scrotum),  there  may  be  considerable  swelling  and 
edema,  as  may  be  seen  in  Fig.  90.  The  eyelids  were  so  swollen  that 
the  patient  could  hardly  open  them. 

Then  the  temperature  falls  suddenly,  the  redness  ceases  to  extend,, 
and  the  skin,  after  slight  desquamation,  resumes  its  normal  condition 
in  about  a  week  from  the  onset  of  the  disease.  In  relapsing  ery- 
sipelas the  whole  process  is  considerably  shorter  and  may  not  take 
more  than  one  or  two  days. 

Erysipelas  of  the  mucous  membranes  is  generally  difficult  to  recog- 
nize, except  when  it  is  an  extension  from  erysipelas  of  the  skin.  The 
mucous  membrane  is  swollen,  edematous,  sodden  and  of  a  deep-red 
color.  Constitutional  disturbance  is  generally  severe.  Erysipelas 
of  the  buccal  mucous  membrane  may  occur  after  tooth  extraction  with 
dirty  instruments.  It  may  cause  death  by  meningitis  or  edema  of  th& 
glottis. 

Diagnosis 

Erythematous  erysipelas  is  so  characteristic  that  it  can  hardly 
be  mistaken  for  other  affections.  The  advancing,  irregular,  raised 
edge  and  shiny  surface  are  enough  to  differentiate  it  from  other  in- 
flammatory conditions. 

Eczema  itches  and  burns  much  more  than  erysipelas. 

Lymphangitis  is  a  diffuse  redness  without  raised  border,  or  hard 
cords  going  directly  to  lymph  glands. 

Fulminating  gangrene  (see  Fig.  109)  is  sometimes  called  by 
Continental  writers  "bronzed  erysipelas,"  but  there  is  no  similarity 
whatever  between  this  condition  and  ordinary  erysipelas.  Bullous, 
erysipelas  might  be  more  confusing. 

130 


kenheimer,  Atlas. 


Tab.  LXXII. 


3maii  Company,  New-York. 


Fig.  91.     Erysipelas  bullosum  hamorrhagicum. 


Diffuse  suppurative  cellulitis  quickly  leads  to  infiltration  and 
pus  I'onnatioii.  II'  tlicrc  arc  any  aliscfsses  in  (M-ysiiielas,  they  always 
remain  very  small. 

Anthrax  ^'nu  he  conruscd  willi  luilldus  ("i-ysi)iclas  (sec  Fig.  91  and 
page  l'A'2)  mucli  nKirc  than  with  the  I'lmniKHi  crythcniatous  form. 

Treatment 

Erysipelas  is  a  contagious  disease  until  after  tlic  period  of 
desquamation. 

The  patient  should  be  isolated  and  the  room  disinfected  after 
recovery. 

The  best  local  apjilications  are  0.5%  carbolic  oil  or  10%  ichthyol. 
Drawing  a  circle  with  tincture  of  iodine  beyond  the  raised  border  is 
but  one  way  of  inducing  active  hyperemia  and  establishing  a  ring 
of  leucocytic  infiltration,  which  acts  as  a  barrier  against  the- 
peripheral  spreading. 

Serum  therapy,  extolled  by  some,  gives  uncertain  results;  in 
theory,  it  does  not  seem  rational,  since  repeated  attacks  of  erysipelas^ 
though  lessening  the  symptoms,  do  not  confer  any  immunity  against 
infection. 

An  intercurrent  erysipelas  often  has  a  beneficial  influence  on  a 
pre-existing  disease  of  the  skin.  It  also  sometimes  brings  about  the 
regression  of  malignant  tumors,  chiefly  sarcoma.  Hence  the  use  of 
toxins  made  by  Coley  in  the  treatment  of  sarcoma,  to  which  reference 
has  already  been  made  (see  page  30). 

Inunctions  of  colloidal  silver  ointment  have  been  foimd  beneficial 
in  streptococcic  infections. 


Fig.  91  shows  a  case  of  hemorrhagic  bullous  erysipelas  of  the 

arm  consecutive  to  a  horse  bite.  Around  the  three  superficial  abra- 
sions due  to  the  teeth  the  skin  is  dark  red,  and  there  are  annular 
extravasations  of  blood.  There  are  also  several  vesicles  filled  with 
turbid  fluid,  in  which  streptococci  were  found. 

There  is  extensive  diffuse  reddening,  especially  on  the  forearm, 
and  a  brownish  coloration  due  to  numerous  extravasations  of  blood 
from  the  smaller  blood-vessels  situated  around  the  lymphatic  vessels. 
In  the  upper  arm  there  is  a  macular  and  cord-like  reddening  due  ta 
lymphangitis.  The  axillary  glands  are  much  swollen  and  painful; 
the  swelling  of  the  forearm  was  so  extensive  that  a  deep  phlegmon- 
was  suspected,  which  suspicion  was  all  the  more  justified  because- 

131 


wounds  caused  by  bites  from  animals  or  men  tend  to  become  severely 
infected,  but  the  symptoms  quickly  subsided  after  suspension  of  the 
arm  and  the  constitutional  disturbance  always  remained  mild.  In 
the  place  where  the  erysipelas  was  hemorrhagic  and  bullous,  there 
occurred  a  superficial  phlegTnonous  inflammation,  which  led  to  gan- 
grene of  the  skin. 

Diagnosis 

Anthrax  also  commences  with  redness  of  the  skin  and  the  for- 
mation of  vesicles  (Fig.  112),  fever  and  rigors,  and  may,  in  its  early 
stage,  be  confounded  with  this  form  of  erysipelas.  But  the  redness 
is  not  so  extensive  in  anthrax,  nor  so  rapidly  developed.  Anthrax 
always  causes  early  gangrene  of  the  skin.  In  doubtful  cases  anthrax 
bacilli  must  be  looked  for  in  the  contents  of  the  vesicles. 

In  the  ease  shown  in  Fig.  91,  which  resulted  from  a  horse  bite, 
there  was  a  suspicion  of  glanders.  But,  in  the  latter  the  redness  is 
punctif  orm  or  macular ;  the  vesicles  are  larger  and  purulent,  and  soon 
rupture,  giving  rise  to  gangTenous  ulcers,  and  the  hadlhis  mallei  is 
found. 

Subcutaneous  phlegmons,  caused  by  virulent  streptococci,  may 
exhibit  an  erysipelatous  redness  of  the  skin,  but  this  only  occurs  in 
the  region  of  the  phlegmon,  and  does  not  extend  so  rapidly  as 
erysipelas.  Vesicles  may  also  form  on  the  skin  in  virulent  strepto- 
coccic infection. 

Phlegmons  due  to  gas-forming  bacteria  (e.g.  malignant  edema, 
Fig.  109)  cause  rapid  redness  and  swelling  of  a  whole  limb.  In- 
crease of  jjressure  in  the  tissues  from  the  formation  of  gas  also 
leads  to  the  development  of  vesicles,  but  these  are  very  large  and 
often  raise  the  epidermis  over  the  whole  part  affected  (Fig.  109). 
In  these  severe  forms  of  lahlegmon  there  are  sigiis  of  general  infec- 
tion from  the  beginning — chills,  delirium,  diarrhea,  dry  tong•^^e,  and 
bacteria  in  the  blood. 

In  all  the  above-mentioned  cases  the  clinical  pictures  may  be  very 
similar,  and  the  diagnosis  should  always  be  established  without  delay 
by  bacteriological  examination.  A  correct  diagnosis  is  all  the  more 
important  because  the  treatment  is  not  the  same  in  the  different  affec- 
tions. In  erysipelas,  anthrax  and  glanders  conservative  measures 
are  indicated,  while  streptococcic  phlegmon  requires  early  incision  to 
prevent  general  infection,  and  in  gas-phlegmon  very  extensive  in- 
cisions, or  even  early  amputation  of  the  limb,  are  necessary  to  save 
the  patient's  life. 

133 


Hockcnliciincr,  Alias. 


Tab.  I.XXIII 


liy.  92.    lii\sipcloid. 


Krbinan  Coinp.Tiiy,  New- York. 


i 


Bockenheimer,  Atlas. 


Tab.  LXXIV. 


Fig.  93.     Panaritium  subepidennoidale. 


Rebiiian  Company,  New-York. 


Fig.  92  shows  a  case  of  an  al'fi'ctinn  very  similar  to  erysipelas, 
and  called  chronic  erysipelas  or  erysipeloid.  It  is  a  bacterial  infec- 
tion of  the  skin,  of  a  very  harmless  nature,  niayhe  caused  by  the 
staphylococcus  albus,  which  has  sometimes  been  found  in  it. 

The  case  was  observed  in  a  cook,  a  few  days  after  handling  game. 
This  is  the  common  etiolosy,  as  erysipeloid  generally  occurs  after 
injuries  to  the  fingers,  especially  by  fish  and  game.  It  is,  therefore, 
more  common  in  venders  of  fish  and  game,  cooks,  butchers,  curriers, 
etc.  SometiiBes  the  injured  spot  is  invisible,  as  the  redness  and  swell- 
ing generally  ap]iear  a  few  days  after  the  injury.  In  otlier  cases 
foreign  bodies  are  found  in  the  skin.  The  affection  has  been  observed 
in  surgeons  after  operating  upon  infected  ])ersons;  it  is  more  common 
in  the  autumn. 

It  begins  with  redness  and  swelling  of  the  fingers.  Like  erysipelas, 
the  redness  has  sharp,  irregular  borders.  The  redness  spreads 
slowly  but  continuously  over  the  whole  finger,  and  may  extend  to 
the  next  finger  and  as  far  as  the  wrist.  At  this  point  the  inflamma- 
tion stops.  There  are  no  constitutional  symptoms;  no  fever  nor 
chills.  The  patients  only  complain  of  itching  and  a  feeling  of  tension 
in  the  skin.  In  some  cases  there  is  lymphangitis,  generally  on  the 
extensor  surface,  as  far  as  the  axilla.  In  rare  cases  adenitis  with 
high  temperature  has  been  noted.  The  sym]itoms  generally  subside 
in  a  week,  but  relapses  are  common.  Supi^uratiou  has  never  been 
observed.  Erysipeloid  differs  from  erysipelas  in  its  chronic,  apyretic 
course,  paler  color  and  demarcation  at  the  wrist. 

Treatment  consists  of  ointments,  rest  and  support  on  splints. 


Figs.  93  to  98,  inclusive,  show  the  in-ineipnl  types  of  the  sup- 
purative conditions  of  the  different  tissues  of  the  finger  grouped 
together  under  the  name  of  panaris,  felon  or  whitlow. 

Whitlows  are  most  frequent  in  workingmen  owing  to  the  numer- 
ous cracks  and  fissures  of  their  skin.  It  often  occurs  after  punctured 
■wounds,  which  directly  inoculate  bacteria  (staphylococci  or,  more 
rarely,  streptococci)  in  the  finger.    It  is  far  from  rare  in  surgeons. 

The  most  superficial  whitlow  is  the  subepidennic  (Fig.  93).  But 
the  most  common,  and  the  most  important  to  know,  is  the  suhcu- 
taneous  variety  (Fig.  94),  because  from  this,  if  improperly  treated, 
derive  all  the  other,  deeper,  and  more  severe  types. 

The   anatomical  disposition  of  the   subcutaneous  tissue  of  the 

133 


fingers  is  peculiar :  vertical  connective-tissue  septa  separate  the  fatty 
tissue  into  a  number  of  distinct  compartments.  If  bacteria  gain  an 
entry  into  one  of  these,  the  inflammation  naturally  is  at  first  circum- 
scribed :  there  is  hyperemia,  exudation  and  tissue  necrosis :  the  latter 
occurs  rapidly  owing  to  the  impairment  of  nutrition  from  the  great 
pressure  in  the  inflamed  area  enclosed  within  inextensible  walls.  In 
this  way  a  necrotic  core  is  formed,  as  in  furuncle.  If  properly  drained 
at  that  time,  no  further  damage  ensues ;  but  if  not,  the  pus  burrows 
in  the  direction  of  least  resistance.  The  tendon  sheath  is  bathed  in 
pus,  finally  involved  and  perforated.  The  result  is  a  tendon-sheath 
suppuration  (Fig.  96). 

Going  still  deeper,  the  pus  may  involve  the  periosteum  of  th& 
phalanges,  the  bone,  and  the  finger  joints  {osteal  and  articular 
whitlow.  Fig,  95). 

The  clinical  symptoms  vary  in  severity  in  proportion  to  the  depth 
of  the  pathological  changes,  and  the  virulence  of  the  bacteria.  In 
subepidermic  whitlow  (Fig.  93),  a  purulent  vesicle  develops,  gen- 
erally on  the  dorsal  surface  of  the  finger,  with  slight  redness  of  the 
surrounding  skin.  The  raised  epidermis  sometimes  shows  several 
yellow  spots,  where  the  pus  breaks  through.  Pain  and  functional 
disturbance  are  slight,  the  inflammation  remaining  local.  Lymphan- 
gitis is  rare,  there  is  no  tendency  to  spread,  and  but  little  or  no 
'constitutional  disturbance. 

In  subcutaneous  whitlow  it  is  quite  otherwise  (Fig.  94).  The 
whole  finger  is  red,  swollen,  flexed  and  extremely  painful,  especially 
at  one  spot.  This  greatest  pain  on  pressure  in  one  spot  is  often 
the  only  symptom  pointing  to  the  primary  seat  of  infection,  as  in 
horny-handed  workmen,  the  latter  is  often  very  difficult  to  see.  In 
a  few  cases  only,  the  skin  gives  way  and  a  yellow  core  becomes  loose 
and  cast  off,  after  which  healing  takes  place  by  granulation  tissue. 
More  usually,  as  the  hard  skin  of  the  palmar  surface  of  the  fingers 
prevents  escape  of  pus,  the  latter  takes  paths  of  less  resistance. 
The  vertical  connective  tissue  septa,  mentioned  above,  guide  it 
toward  the  peritendinous  zone,  where  it  may  spread  along  the  whole 
length  of  the  tendon.  It  may  also  reach  the  loose  connective  tissue 
on  the  dorsal  surface,  and  give  rise  to  marked  redness,  swelling  and 
edema,  while  inflammatory  signs  may  be  slight  or  absent  at  the 
primary  focus  of  infection  on  the  flexor  surface.  There  is  some 
lymphangitis  of  the  hand  and  forearm,  a  moderate  fever  (102°)  and 
constitutional  disturbance. 

13-i 


BockciilR-iiiRT,  Atlas. 


Tab.  I. XXV. 


\-\g.  94.    Paiiariliiim  subculaiicuin         l-\•nlpllallL;ili^  acuta. 


Rcbm.Tii  Coiiiiwiiy,  Nc\v-\ork. 


Bockenheimer,  Atlas. 


Tab.  LXXVI. 


Fig.  95.     Panaritium  ossale  et  articulare. 


Pebman  Company,  New- York. 


An  intcrcstiii.n'  \-ai-icty  nl'  sulicutiiiicdiis  whitlow  i>  interdigilal 
whitlow,  sliowu  in  Fig.  97.  It  is  a  snln-ntaueous  suppiiratiou  Ito- 
twccn  tlio  laeiaearpal  i)une.s;  in  the  ac;tual  case,  between  the  tliunih 
anil  inilicatoi"  finger.  Redness  and  edema  are  marked  on  the  dorsal 
surface,  and,  as  pus  is  i)resent  in  more  considoi-alilo  f|uaiitify  than 
in  ordinary  suhciilaueous  felon,  fluctuation,  wliich  is  laic  in  the  latter, 
is   ]>r('S(Mit. 

The  syinptuiiis  arc  Jimst  severe  in  tendinous  whitlow  (Fig.  96)- 
There  is  more  swelling  of  the  finger,  and  tlie  participation  of  the 
tendon  sheath  is  evidenced  by  the  flexion  of  the  finger.  Tiiere  is 
)>aiTi  (in  pressure  along  the  whole  tendon  sheath,  and  usually  over 
the  whole  ])alin.  Movement  of  the  tendon  causes  great  pain,  and 
extension  is  almost  impossible.  Lymphangitis  and  erysipelatous 
reddening  often  extend  far  beyond  the  seat  of  infection.  There  are 
chills  and  fever  (104°),  sleeplessness,  and  considerable  mnlaise. 

If  the  tendon  sheath  of  the  thumb  or  little  finger  is  infected,  the 
pus  may  extend  along  the  course  of  these  sheaths  as  far  as  the  wrist; 
whereas,  su])puration  in  the  tendon  sheaths  of  the  second,  third  and 
fourth  fingers  does  not  extend  beyond  the  metacarpo-phalangeal 
joints,  where  these  tendon-sheaths  end. 

In  the  wrist  the  tendon-sheaths  widen  and  lie  so  close  together 
that  suppuration  may  extend  from  one  to  the  other.  In  this  way, 
infection  of  the  tendon-sheaths  of  the  thumb  may  result  from  that  of 
the  tendon  of  the  little  finger;  and  inversely,  infection  of  the  little 
finger  may  come  from  the  thumb.  This  has  been  called  V-shaped 
whitlow.  It  is  obvious  that  infection  of  both  tendon-sheaths  causes 
more  severe  symptoms — high  fever  and  much  constitutional  disturb- 
ance. The  thumb  and  little  finger  are  flexed,  swollen  and  very  pain- 
ful on  pressure.  The  pus  often  breaks  through  the  sheaths  and 
spreads  between  the  muscles  of  the  forearm  up  to  the  elbow  joint. 
In  other  cases  the  wrist-joint  is  infe(>ted.  Such  cases  may  give  rise 
to  general  sepsis. 

V-shaped  whitlow  is  recognized  by  its  severe  clinical  symptoms 
and  typical  appearance.  In  the  early  stages  there  is  often  i)ain.  red- 
ness and  swelling  in  the  palm,  or  on  the  flexor  surface  of  the  wrist. 
When  suppuration  has  existed  for  some  time  and  become  extensive 
it  seeks  a  way  to  the  surface.  Thus  fistuhT  are  formed  along  the- 
tendon-sheaths,  discharging  much  pus,  and  often  exj losing  the 
greenish-yellow  remains  of  the  necrosed  tendon  (Fig.  96).  The 
orifices  of  these  fistuhx.'  are  surrounded  bv  flaiiliv,  unhealthv  uranu- 


135 


lations,  which,  as  mentioned  before  (Fig.  56),  indicate  necrosis  in  the 
■deeper  parts. 

In  periosteal  and  osteal  whitlows,  which  generally  occur  at  the 
ends  of  the  fingers,  the  periosteum  and  bone  are  surrounded  by  pus 
and  destroyed.  In  the  terminal  phalanx  total  necrosis  may  occur. 
A  fistiila  forms  and  discharges  the  fetid,  slimy  pus  characteristic  of 
necrosed  bone.  Frequently  dead  bone  is  eliminated  (Fig.  95).  Parts 
of  the  skin  may  become  necrosed,  so  that,  eventually,  the  whole 
finger-joint  may  be  lost.  Beginning  with  sharp  pain,  the  acute  stage 
gradually  becomes  more  chronic,  and  in  this  stage  bone  involvement 
may  be  overlooked. 

In  the  first  and  second  phalanges  there  is  often  infection  of  the 
joints,  either  secondarily  to  periostitis,  or  directly  from  the  surface. 
Articular  whitlow  generally  manifests  itself  by  chills.  The  joint  is 
fixed  in  a  position  of  flexion  and  is  very  painful  on  movement.  The 
capsule  and  ligaments  are  soon  destroyed,  and  erosion  of  the  cartilage 
causes  grating  on  motion.  Articular  whitlow  may  also  give  rise  to 
general  sepsis. 

3iagnosis 

Tuberculous  and  syphilitic  inflammations  are  more  chronic 
and  cause  less  pain  and  fever.  They  do  not  heal  after  incision,  but 
require  specific  treatment. 

It  is  not  always  easy  to  diagnose  the  stage  of  the  whitlow. 
Patients  of  the  working-class  generally  come  so  late  for  treatment 
that  there  is  often  infection  of  the  tendon-sheath,  periosteum  and 
joint.  In  other  cases  the  pain  is  so  severe  as  to  suggest  tendinous 
whitlow,  while  it  is  only  subcutaneous.  A  correct  diagnosis  can  often 
only  be  made  after  incision. 

Treatment 

All  whitlows  require  early  incision.     In  subepidermic  whitlow 
the  purulent  bulla  must  be  opened,  its  edges  pared  off,  an  antiseptic 
dressing  applied,  and  the  arm  suspended  in  a  sling.     Subepidermic  ' 
whitlow  may  cause  infection  of  the  deeper  tissues,  and  there  is  also 
the  danger  of  erysipelas.    Hence,  do  not  consider  it  too  lightly. 

Subcutaneous  whitlows  should  be  incised  as  soon  as  possible, 
under  an  anesthetic.  Schleich's  infiltration  anesthesia  does  not 
work  well  in  inflamed  tissues,  but  regional  anesthesia  is  very  prac- 
tical on  the  fingers.    However,  general  anesthesia  should  be  resorted 

136 


Bockenheimer,  Atlas. 


Tab.  LXXVII. 


Rebman  Coniiiany,  New- York, 


to  in  all  cases  wlioro  the  oxtoiit  of  the  suppuration  is  not  clear.  Do 
not  let  yourself  be  inttu('nce<l  hy  the  sometimes  enormous  swelling  of 
the  dorsal  surface  of  the  hand.  Tlie  primary  focus  is  in  the  pain;. 
Therefore  make  an  incision  over  the  primary  focus,  away  fi'om  the 
midline  and  the  tendon.  The  incision  must  be  lar.c^e  enon,2:h  to  allow 
of  a  free  exnminnlidu  of  the  wound.  Not  ascertaining  the  extent  of 
the  suppuration  nl  llic  lime  nf  incision  is  ,a:i'Oss  carelessness,  which 
may  lead  to  serious  damage  to  the  finger.  Hut  the  incision  need  not 
be  as  extensive  as  was  urged  before  hypcicini:!  trcitincnf  ciiiic  in 
favor. 

There  is  often,  in  suhcutaiicmis  rdon,  a  "rollar  hiiltoii"  abscess, 
that  is,  two  pus  coilectioiis.  a  suitcilicial  and  a  deejier  one  connected 
by  a  narrow  perpendicular  tract.  Particular  search  nnist  be  made 
for  this  condition,  so  as  not  to  neglect  the  deeper  collection. 

Tendon-sheath  whitlow  requires  very  careful  treatment,  in  order 
to  preserve  the  tendon  and  the  function  of  the  finger.  Bier's  passive 
hyperemia  renders  here  great  services,  because  it  enables  us  to 
replace  the  long  incisions  formerly  used  by  several  smaller  incisions 
along  the  edges  of  the  tendon.  Thus  -we  do  not  have  to  fear  scar 
retraction  (Fig.  64)  and  we  save  the  finger  and  its  function.  When 
carefully  applied  and  watched,  there  is  no  danger  of  letting  the  infec- 
tion spread,  as  has  been  repeatedly  charged.  But,  unfortunately, 
many  cases  come  too  late  for  effective  treatment.  Saving  tlie  tendon 
function  is  out  of  tlie  question:  preventing  general  sepsis  by  hasty 
and  large  incisions  is  all  that  can  be  done. 

In  osteal  whitlow  necrosed  bone  must  be  removed  if  present.  In 
the  terminal  i)halanx  it  is  often  sufficient  to  remove  the  peripheral 
end.  If  the  joint  is  much  destroyed  resection  of  the  bone,  or  even 
amputation,  may  be  required. 

The  after-ireatment  is  very  important  in  all  finger  suppurations, 
but  especially  in  tendinous  whitlow.  Hyperemia  methods  have  done 
away  with  the  drains  and  packing  formerly  so  much  in  honor.  Pack- 
ing in  tendon  sheath  supjniration  brings  about  desiccation  of  the  ten- 
don. The  pus  is  gently  squeezed  out  every  day;  newly  formed 
abscesses,  if  any,  are  incised;  an  irrigation  with  warm  saline  solution 
may  be  given,  and  a  large  loose  dressing  applied.  Passive  motion  is 
begam  from  the  first  day,  of  course  with  the  utmost,  gentleness.  This 
alone  can  save  the  tendon  function  by  preventing  the  development 
of  adhesions  between  the  tendon  and  its  sheath. 

Patients  should  be  kept  in  tlic  hos)iital.  Sevcrt-  forms  of  finger 
sni>))urati()n  arc  not   fit  foi'  anibulatoi'v  treatment. 

137 


Fig.  98  shows  a  type  of  subepidermie  whitlow,  having  special 
features  on  account  of  its  location;  it  is  the  peri-ungual  ivhitloiv  or 
paronychia.  The  skin  is  bluish-red  and  tender  to  the  touch.  The 
nail  bed  is  red,  infiltrated,  and  painful  on  pressure. 

Paronychia  may  result  from  punctured  wounds,  tearing  of  the 
nail,  foreign  bodies  or  manicuring  with  dirty  instruments.  There  is 
often  suppuration  around  the  nail,  which  is  raised  from  its  bed,  may 
become  quite  loose,  and  generally  falls.  In  severe  cases  there  is  much 
pain,  fever  and  lymphangitis. 

Syphilitic  chancre  of  the  finger  often  resembles  paronychia. 
It  begins  with  redness  and  hard  infiltration,  which  develops  into  an 
unhealthy  ulcer  with  flabby  granulations.  This  is  followed  by  painful 
infiltration  of  the  lymph  vessels  and  glands.  This  form  of  chancre 
is  very  chronic  and  painful  (thus  differing  from  most  other  chancres). 
Syphilitic  chancre  shouFd  be  borne  in  mind  in  every  case  of  chronic 
paronychia  which  is  refractory  to  treatment.  It  is  especially  com- 
mon in  medical  men  and  midwives. 

Tuberculous  infection  of  the  nail  bed  may  also  occur  among  physi- 
cians and  nurses.  This  begins  as  a  dark-red  infiltration  of  the  skin. 
Nodules  then  develop  and  break  down  into  an  ulcer  with  flat,  irregu- 
lar borders.  The  tuberculous  granulations  are  grayish-red  and  bleed 
easily.  This  affection  is  very  chronic.  The  nail  may  be  lost  and 
replaced  by  thickened  tissue  in  both  tuberculous  and  syphilitic 
paronychia.  In  some  cases  the  whole  finger  may  be  destroyed.  The 
diagnosis  of  tuberculous  paronychia  can  sometimes  only  be  settled 
by  microscopic  examination,  or  by  inoculation  to  the  guinea  pig.  The 
diagnosis  of  syphilitic  chancre  is  confirmed  by  finding  the  spirochceta 
pallida  in  scrapings. 

If  the  inflammation  is  not  around  the  nail  bed,  but  under  it,  we 
are  dealing  with  the  condition  called  suh-ungual  iv-hitloiv.  Owing  to 
pressure  of  the  nail,  the  virulence  of  the  infecting  bacteria  is  in- 
creased, so  that  the  inflammation  rapidly  spreads  and  soon  leads 
to  necrosis  of  the  tissues.  Sub-ungual  whitlow  causes  severe  pain 
and  lymphangitis.  It  is  often  overlooked,  as  the  changes  under  the 
nail  are  not  at  first  visible,  and  the  first  sign  is  usually  a  yellow  color- 
ing seen  under  the  nail.  The  diagnosis  is  suggested  by  the  severe 
pain  elicited  by  pressure  on  the  nail.  As  the  pus  cannot  break 
through  the  nail,  it  extends  deeply  and  may  cause  necrosis  of  the  ter- 
minal phalanx  by  infection  of  the  periosteum.  Corns  and  exostoses 
may  also  develop  under  the  nail  and  cause  inflammation  with  severe 
pain. 

138 


liockeiiliciiiicr,  Alias. 


Tab.  LXXVIII. 


Rcbnian  CoiitiMiiy.  Nc\v-Voil<. 


Trcatmnit 

]*;ii'f)iiyclii;i  rci|uii-('s  early  iiicisidii  licforc  llic  |iiis  lias  loosened 
the  nail;  this  is  tlic  only  ciiancc  nl'  .->avini;-  (lie  lallcr,  an<i  the  growth 
of  a  new  nail  reqnires  quite  sonic  tiiiic.  It  is  hot  to  make  a  liorse- 
shoe  incision  through  the  soft  jiai'ts  some  dislance  from  tlie  nail, 
to  avoid  interfering  with  its  nntrilioii.  The  hand  should  he  ininio- 
hilized  for  a  IVw  days,  if  tlic  nail  is  cxtciisixcly  scjiavated  it  must 
be  removed. 

Tuberculous  paronychia  rci|uin's  treatment  by  the  sliarp  spoon 
or  Paqifelin's  cautery.  Sypliilitic  chancre  calls  for  immediate  anti- 
syphilitic  treatment  (see  page  186). 

In  sub-ungual  whitlow  the  nail  may  be  pared  down  with  a  knife, 
under  local  anesthesia,  so  that  the  inflammatory  area  can  be  incised. 
If  suppuration  is  extensive  the  nail  must  be  removed. 


Fig.  99  shows  an  ingrowing  toenail  on  the  outer  side  of  the 
right  great  toe.  The  thickened  soft  parts  have  grown  over  the  border 
of  the  nail.  There  is  a  purulent  discharge  from  unhealthy  granula- 
tions. The  nail  is  so  imbedded  in  the  swollen  soft  parts  that  it  is 
onlj'  partly  visible. 

Ingrowing  toenail  affects  almost  exclusively  the  nail  of  the  great 
toe;  generally  the  outer  side,  less  often  the  inner  side,  occasionally 
both. 

It  often  occurs  in  connection  with  hallux  valgus  (Fig.  64) ;  it  may 
also  be  caused  by  anomalies  of  the  nails  or  toes,  by  wearing  too  short 
boots,  or  by  cutting  the  nails  too  much  at  the  sides.. 

Ingrowing  toenail  gives  rise  to  severe  inflammation  of  the  soft 
parts  next  the  border  of  the  nail;  first  redness  and  swelling,  after- 
ward ulceration  and  granulation  tissue.  The  inflammation  is  usually 
limited  to  a  small  area,  but  may  sometimes  spread  over  the  whole 
nail-bed.  The  affection  causes  considerable  pain  and  often  prevents 
the  patient  from  walking.  There  may  be  lymphangitis.  If  both  sides 
of  the  nail  are  affected  the  symiitoms  are  naturally  more  severe. 

Differential  diagnosis 

Sub-ungual  exostosef<  may  cause  inflammation  artniiid  the  nail,  but 
in  these  cases  the  latter  is  always  raised  in  front  and  is  very  tender 
to  pressure.  Sjiphilific  chancre  has  also  been  known  to  occur  on  the 
great  toe,  after  sucking  the  toe  (Bochoihe'nner). 

139 


Treatment 

Ingrowing  toenail  may  be  avoided  by  prophylactic  treatment.  The 
toenails  should  be  cut  straight  and  not  too  short,  so  that  the  free 
border  extends  beyond  the  soft  parts,  especially  at  the  sides.  Atten- 
tion should  be  paid  to  cleanliness  and  to  the  wearing  of  properly 
made  boots.  In  slight  cases  the  edge  of  the  nail  may  be  raised  from 
the  inflamed  soft  parts  by  a  small  gauze  tampon,  or  partial  excision 
of  the  nail  may  be  performed. 

But  in  severe  cases  these  methods  are  useless.  Avulsion  of  the 
nail,  which  was  formerly  the  procedure  most  frequently  em^Dloyed,  is 
also  ineffectual,  as  the  condition  recurs  after. 

The  most  rational  method  is  excision  of  the  whole  lateral  border 
of  the  nail  together  with  the  inflamed  soft  parts,  down  to  the  bone; 
taking  care  to  include  the  posterior  part  of  the  matrix,  so  that  recur- 
rence cannot  take  place.  The  wound  is  dressed  with  aristol  and 
sterilized  gauze  and  immobilized  for  a  week,  after  which  the  wound 
is  usually  healed.  This  was  done  with  good  result  in  the  case  shown 
in  Fig.  99. 

In  ingrowing  toenail  affecting  both  sides  the  same  operation  is 
performed  on  each  side,  leaving  the  middle  part  of  the  nail  in  place. 


Fig.  100  shows  an  inflammatory  condition  affecting  the  whole  of 
the  second  toe  and  extending  to  the  dorsum  of  the  foot.  The  skin 
on  the  dorsal  surface  of  the  toe  was  at  first  raised  by  purulent  blisters. 
After  these  had  broken,  the-  necrosed  epidermis  came  away,  exposing 
a  considerable  area  of  the  corium.  The  redness  and  swelling  are 
most  marked  over  the  first  interphalangeal  joint,  which  was  very 
painful  on  movement.  On  the  dorsal  side  of  the  joint  fluctuation  was 
present.  The  remains  of  a  corn  are  seen  on  the  great  toe,  in  the  form 
of  a  yellowish-white  projection,  together  with  a  fistula  leading  to  the 
deeper  parts,  where  there  was  an  infected  bursa  communicating  with 
the  joint.  The  corn  on  the  second  toe  was  due  to  its  being  exposed  to 
pressure  from  its  crooked  position. 

Corns  are  circumscribed  thickenings  of  the  horny  layer  of  the 
epidermis.  They  generally  occur  on  the  great  and  little  toes ;  some- 
times between  the  toes,  espedally  when  these  are  crooked  owing  to 
bad  boots.  They  also  develop  in  connection  with  hallux  valgus, 
hammer-toe  (see  Fig.  64),  club-foot,  etc.  The  more  they  project 
above  the  level  of  the  skin  the  more  painful  they  are  to  pressure. 
They  differ  from  the  diffuse,  horny  thickenings  which  are  observed 

140 


Bock'ciilieitner,  Atlas. 


Rcbnian  Company,  Ne\v-\'ork. 


on  the  hands,  and  consist  in  a  circumscribed  horny  formation,  which 
grows  from  a  soft,  conical  core  situated  in  the  depth  of  tiie  cutis. 
"When  the  liorny  layer  is  removed  the  soft  yellowish-white  core  is 
seen  in  the  centre.  Lacerations  caused  hy  unskillful  cuttin.ir  of  corns 
may  easily  give  rise  to  subcutaneous  abscess.  Undej'neath  large 
corns  there  usually  is  a  bursa,  which  is  liable  to  become  inflamed 
(bunion)  from  external  pressure.  The  inflammatory  exudation  from 
the  bursa  generally  discharges  by  a  fistula  near  the  corn  (Figs.  64 
and  100).  Septic  infection  of  the  Imrsn  ni;iy  nrisc  tlii-ongh  the 
fistula,  and  extend  to  the  neiglilioring  tendon-slieath  or  joint.  .loint 
infection  is  especially  frequent  when  the  bursa  communicates 
with  the  joint;  and  is  manifested  by  severe  local  inflammation,  fever, 
chills  and  constitutional  disturbance.  All  these,  and  lymphangitis 
of  the  foot  and  leg  were  present  in  the  case  represented  in  Fig.  100. 
Purulent  arthritis  may  even  give  rise  to  fatal  general  sepsis,  wliich 
has  also  been  seen  as  a  consequence  of  removal  of  corns  with  unclean 
instruments. 

Treatment 

Prophylaxis  of  corns  consisfs  in  cleanliness  and  the  wearing  of 
proper  boots.  If  one  forms  it  should  be  removed  with  a  sterile  knife. 
It  is  not  sufficient  to  pare  off  the  horny  layer;  the  deeply  situated  coi'e 
must  also  be  removed,  otherwise  recurrence  takes  place.  Other  meth- 
ods, such  as  the  application  of  salicylic  collodion  (10%)  only  loosen 
the  horny  layer  and  do  not  prevent  recurrence. 

If  a  bursa  forms  under  the  corn,  it  must  either  be  incised  and 
packed,  or,  better,  excised.  If  suppuration  spreads  to  the  joint  this 
must  be  opened;  in  some  cases  resection  or  exarticulation  may  be 
necessary. 

In  the  case  shown  in  Fig.  100  the  joint  was  opened  on  the  dorsal 
surface  by  a  transverse  incision,  and  the  su]3erficial  suppuration  by 
another  incision  on  the  dorsum  of  the  foot.  The  corn  and  bursa  were 
excised  subsequently. 


Fig.  101  shows  a  progressive  gangrenous  phlegmon,  due  to  a 

combination  of  pyogenic  and  putrefactive  bacteria,  in  a  diabetic 
patient  in  whom,  owing  to  the  general  debilitation  of  the  body,  such 
infections  are  always  severe.  But  this  is  more  than  the  ordinary 
progressive  suppuration  common  in  diabetics.  Following  a  slight 
wound  of  the  great  toe,  a  subcutaneous  suppuration  rapidly  s]-iread 

141 


to  the  tendon-sheatli  and  the  joint,  necessitating  amputation  of  the 
toe.  Although  this  operation  was  performed  in  sound  tissue,  further 
suppuration  occurred  on  the  sole  of  the  foot  and  gained  rapidly,  so 
that  the  soft  parts,  sinews,  muscle  and  fascia,  were  destroyed  and 
the  metacarpus  was  involved,  as  shown  by  the  great  swelling  around 
it.  The  periosteum  was  already  loosened  and  the  cortex  and  medul- 
lary cavity  infected.  A  high  temperature,  chills,  a  dry  tongue  and 
drowsiness  were  suggestive  of  impending  general  sepsis,  but  after  a 
while  the  infection  assumed  a  more  chronic  course.  Under  lumbar 
anesthesia,  amputation  was  performed,  above  the  knee,  because  of 
the  thrombo-phlebitis  and  lymphangitis  in  the  leg,  and  of  the  ad- 
vanced arteriosclerosis.  The  patient  recovered.  (Compare  with 
Fig.  139,  diabetic  gangrene). 

The  appearance  of  the  wound  in  this  form  of  inflammation  is 
characteristic.  Owing  to  the  fibrinous  exudation,  the  wound  is  coated 
with  a  diphtheroid  membrane.  This  condition  has  been  called 
"wound  diphtheria";  but  this  is  a  misnomer,  and  it  is  better  to  use 
the  term  diphtheroid  (true  infection  of  wounds  by  the  diphtheria 
bacillus  is  rare).  In  putrefactive  phlegmon  dry,  unhealthy  granu- 
lations are  present  along  with  the  diphtheroid  membrane.  There  is 
also  a  sanious,  fetid,  dirty  discharge  from  the  wound,  containing 
numerous  pieces  of  necrosed  tissue.  Similar  conditions  are  found  in 
wounds  in  general  infection. 

If  an  incision  is  made  in  these  cases,  all  the  tissues  are  seen  to 
be  bathed  in  a  turbid,  green  fluid  and  in  a  state  of  necrosis,  often 
consisting  only  of  yellowish-green  necrotic  shreds.  The  skin,  fascia, 
muscles  and  tendons  are  the  first  to  be  destroyed,  while  the  bones 
resist  Ibnger,  but  are  finally  involved. 

Treatment 

In  those  cases  free  incisions  must  be  made  in  the  diseased  tissues 
as  early  as  possible,  as  general  sepsis  develops  rapidly  and  toxemia 
is  extremely  marked.  If  the  process  continues  its  onward  march  in 
spite  of  the  incisions,  amputation  through  healthy  tissues  must  not 
be  delayed  too  long;  otherwise  the  patient  will  succumb  in  spite  of 
amputation. 

In  the  phlegmonous  inflammations  occurring  in  diabetes,  which 
often  begin  in  the  toes  and  spread  destruction  over  the  whole  foot  in 
a  few  hours,  the  conditions  are  especially  serious.  If,  after  extensive 
incisions,  the  temperature  does  not  immediately  fall,  amputation  must 
be  performed ;  otherwise  general  infection  will  supervene  rapidly.    In 

143 


Bockenheimer,  Atlas. 


Fig.  102.     Phlegmone  colli  -  Plilegmon  ligneux. 


Rebraan  Company,  New- York. 


any  case  of  phloffinonoiis  iiifliniimntioTi  in  ;i  (li,i])('fic  pjilicntdc-itli  may 
result  from  coma  or  lieart  failure. 


Fig.   102   shows  an  acute  inflammation  of  the  submaxillary 

lymph  glands  with  ronnation  of  an  abscess  under  the  skin. 

Sul)cutaneous  and  subfascial  adenophleg'mons  of  the  neck  are 
common,  owing  to  the  numei'ous  groups  of  lymph  glands  in  this 
region,  and  the  multiple  places  from  which  absorption  may  take  place. 
All  septic  conditions  of  the  mouth  and  pharynx  may  be  the  starting 
point  of  an  adenophlegmon.  Eczema  and  other  affections  of  the 
head  and  face  may  play  the  same  role. 

Staphylococci  are  the  usual  agents,  sometimes  streptococci,  and 
then  the 'infection  is  nioic  sevei'o  and  may  assume  the  highly  virulent 
character  of  the  diffuse  cellulitis  of  the  neck,  known  as  Ludwig's 
angina.^  Occasionally  other  bacteria  are  present.  Putrefactive  bac- 
teria may  reach  the  abscess  cavity  from  the  mouth;  hence  the  pecul- 
iarly offensive  smell  of  the  pus  in  many  of  these  perebuccal  abscesses. 

Subcutaneous  phlegmon  in  the  neck  manifests  itself  by  redness  of 
the  skin,  inflammatory  infiltration  and  fever;  later  on  fluctuation  can 
be  made  out.  In  nearly  all  cases  a  circumscribed  abscess  forms  on 
one  side  of  the  neck.  Large  abscesses  may  cause  dyspnea  by  pres- 
sure on  the  larynx,  and  dysphagia  by  pressure  on  the  esophagus. 

Lateral  abscesses  are  due  to  suppuration  of  the  submaxillary 
group  of  glands;  median  collections  are  developed  in  the  submental 
group  and  are  due  to  lesions  of  the  lower  lip. 

Subfascial  suppurations  in  the  neck  arise  from  the  deep  lymphatic 
glands.  They  develo]i  after  lesions  in  the  pharynx,  esophagus  and 
larynx,  also  after  tonsillitis  and  scarlet  fever,  and  are  more  danger- 
ous on  account  of  their  deep  situation.  They  develop  with  fever, 
chills  and  diffuse  inflammatory  infiltration  in  the  neck,  while  fluctua- 
tion is  often  absent.  This  deep  suppuration  manifests  itself  by 
cyanosis  of  the  face,  oblique  position  of  the  head,  trismus  of  the  jaw, 
attacks  of  asphyxia  and  difficulty  in  swallowing.  The  pus  may  burrow 
down  to  the  supraclavicular  fossa  or  in  the  axilla. 

'Tlie  mcuniiif.'  of  (lie  term  "Ludwiff's  angina"  is  not  always  altogether  <-lear.  lie<-au?e 
it  lias  lii'cn  applied  to  a  variety  of  conditions.  Some  consider  "Ludwig's  angina"  as  the 
phlegmon  of  the  suhmaNillary  salivary  gland;  others  use  the  name  for  all  eases  of  diffuse 
cellulitis  originating  in  the  upper  part  of  the  neck.  The  correct  definition  is:  a  difTuse 
cellulitis  of  the  neck  beginning  in  the  floor  of  the  mouth  as  a  sublingual  phlegmon 
{Thumas). 

H  must  not  be  forgotten  that  there  are  sulimaxillarv  li/mph  glands  within  the  fascial 
eonii)artment  that  encloses  the  submaxillary  snliriirn  gland:  which  lymph-glands  often  be- 
come tlie  seat  of  septic  processes  of  higli  virulence  because  of  the  inextensibility  of  the  sub- 
inaxillary  fascia  whicli  cncloscx  tlicin. 

143 


In  Ludwig's  angina  there  is  no  pus,  but  a  dii'ty,  fetid,  greenish 
fluid,  which  infiltrates  all  the  tissues.  Dysphagia  and  dyspnea  are 
extreme,  and  the  toxemia  is  very  marked.  Such  cases  are  generally 
fatal  if  not  operated  on  promptly  (sepsis,  asphyxia).  Diffuse  in- 
flammation may  also  occur  after  operations  on  the  neck,  larynx  and 
esoijhagris,  and  cause  death  by  extension  to  the  mediastinum. 

A  special  type  of  cervical  phlegmon  is  interesting,  namely,  the 
so-called  "woody  phlegmon"  (phlegmon  ligneux).  It  is  a  chronic 
inflammation  of  the  neck,  consecutive  to  lesions  of  the  mouth  and 
pharynx,  probably  caused  by  bacteria  of  slight  virulence,  which  give 
rise  to  an  infiltration  of  wood-like  hardness,  often  extending  over  the 
whole  neck,  with  but  mild  inflammatory  symptoms.  The  skin  is 
slightly  blue,  edematous,  and  pits  on  pressure.  There  is  no  fever  nor 
pus  formation.  The  infiltration  may  cause  dyspnea  by  pressure  on 
the  larynx.  When  incised,  a  dirty,  greenish-yellow  fluid  is  seen  in 
the  subcutaneous,  subfascial  and  intermuscular  tissues,  extending 
through  the  whole  region  of  the  neck. 

Differential  diagnosis 

This  has  to  be  made  from  alveolar  periostitis  (Fig.  104),  osteo- 
myelitis  of  the  lower  jaw  (Fig.  105),  tuberculous  adenitis  (Fig. 
124),  and  cystic  tumors  in  the  neck  (blood,  dermoid,  sebaceous, 
branchial  cysts).  Changes  in  the  bone  are  revealed  by  an  incision  in 
the  case  of  periostitis  and  osteomyelitis.  Acute  symptoms  and  fever 
are  absent  in  the  other  formations,  but  suppuration  of  a  cystic  tumor 
may  resemble  glandular  suppuration.  In  cases  of  deep  suppuration 
in  the  neck,  retro-pharyngeal  abscess  must  be  borne  in  mind,  espe- 
cially in  infants. 

Woody  phlegmon  of  the  neck  may  be  mistaken  for  incipient  actino- 
mycosiSf'hnt  the  latter  soon  gives  rise  to  a  fistula,  which  discharges 
pus  mixed  with  the  characteristic  yellow  bodies  (Fig.  115)- 

Treatment 

The  treatment  is  incision  in  all  cases.  In  subcutaneous  phlegmons 
with  a  tendency  to  become  circumscribed,  incision  should  be  deferred 
until  an  abscess  forms.  Under  local  anesthesia  an  incision  is  made 
through  the  skin  at  the  lowest  part  of  the  abscess,  and  the  pus  evacu- 
ated by  means  of  blunt  dressing  forceps.  In  the  submaxillary  region 
the  facial  nerve  and  vessels  must  be  avoided. 

But  in  all  deep  suppurations  of  the  neck  we  must  not  wait  for 
the  appearance  of  a  superficial  abscess,  nor  for  fluctuation.    A  free 

144 


Bockenlieimer,  Atlas. 


Tab.  LXXXI. 


Fig.  103.    Periostitis  alveolaris  purulenta  —  Parulis. 


Rebman  Company,  New-Yorl(. 


incision  must  be  made  alon,i>'  the  iiiiifr  hoidor  of  tlio  storno-mastoid 
muscle.  Extensive  cases  ic<|uiii'  rumitci-  iiici>iuii>.  In  Ludniff's 
angina,  tlie  thermocautery  is  usetul.  No  I'uhher  drains  must  be  left 
in  contact  witli  tlie  1)1^  l)lood-vesselM  of  the  neck,  for  fear  of  pressure 
ulceration.  Jjari^e  incisions  in  the  nock  heal  very  well  and  often  leave 
only  surprisingly  small  scars. 

Woody  ])hlegmon  sometimes  requires  multiple  incisions. 

In  all  cases  of  cervical  cellulitis  in  wliicli  there  is  nnich  inliltration 
of  the  floor  of  the  mouth,  with  diHicully  in  lucathinn-  ,ind  swallowing, 
preliminary  tracheotomy  is  advisable,  as  death  might  occur  from 
sudden  edema  of  the  glottis  during  anesthesia. 


Fig.  103  shows  a  purulent  alveolar  periostitis  of  the  lower  jaw, 
witli  fonnation  of  a  subcutaneous  abscess,  which  is  the  usual  termina- 
tion (Panilis). 

This  comjnon  condition  is  caused  by  lesions  of  the  gum  (tooth 
extraction  with  unclean  instruments),  fractures  of  the  jaw,  dental 
caries  or  fistula. 

Infection  of  the  periosteum  of  the  alveolar  portion  of  the  lower 
jaw  gives  rise  to  a  circumscribed  subperiosteal  accumulation  of  pus, 
which  descends  to  the  sulmiaxillary  region  and  lies  over  the  fascia, 
covering  the  submaxillary  gland.  The  signs  of  pui'ulent  inflammation 
are  most  apparent  in  this  region,  while  symptoms  at  the  seat  of  infec- 
tion are  often  slight. 

The  symptoms  commence  with  fetor  of  the  breath,  fever  and  chills, 
and  inflammatory  infiltration  in  the  submaxillary  region.  Soon  after- 
ward the  ])resence  of  fluctuation  indicates  abscess  formation,  after 
which  the  symptoms  somewhat  abate.  In  most  cases  the  suppuration 
is  circumscribed,  but  sometimes  it  is  diffuse  and  causes  considerable 
infiltration  of  the  soft  parts,  swelling,  and  redness  of  the  side  of  the 
face.  There  is  often  in  those  cases  trismus  and  edema  of  the  buccal 
mucosa,  with  difficulty  in  mastication  and  often  dysjmea.  In  these 
diffuse  forms  there  are  severe  constitutional  symptoms — chills,  high 
fever,  headache,  etc. 

Although  the  circumscribed  form  is  not  dangerous,  the  diffuse 
foi'7n  may  be  quite  serious.  es]iecially  when  imiiroperly  treated.  If 
incision  is  too  long  delayed.  ,is  \va>  tlic  case  in  the  patient  shown  in 
Fig.  103,  the  bone  may  be  denuded  of  periosteum  for  a  cojisiderable 
length,  or  there  may  develop  osteomyelitis  of  the  jaw  (Fig.  104). 

In  the  u]i]ior  jaw,  infection   of  the  periosteum   may   also  (^ause 

145 


subperiosteal  suppuration,  wliich  here  does  not  meet  with  such  favor- 
able anatomical  conditions  for  propagation  to  the  subcutaneous  tissue 
as  in  the  lower  jaw.  Small  abscesses  caused  by  morbid  conditions 
of  the  teeth  may  burst  into  the  mouth  and  cause  no  trouble,  but  more 
virulent  infections  may  cause  osteomyelitis  of  the  iipper  maxilla, 
which  rapidly  spreads  to  all  the  bones  of  the  face,  and  often  causes 
death  by  general  j^yemia.  In  these  cases  there  is  infiltration  of  the 
upper  part  of  the  face,  edema  of  the  eyelids,  high  temperature,  chills, 
headache,  etc. 

In  abscesses  due  to  alveolar  jDeriostitis,  staphylococci  are  gen- 
erally associated  with  some  of  the  putrefactive  bacteria  of  the  buccal 
cavity.  Hence  the  fetid,  dirty,  reddish-brown  pus,  mixed  with 
broken-down  tissue  that  is  generally  found  on  incision. 

Diagnosis 

Subcutaneous  abscesses  due  to  alveolar  periostitis  of  the  lower 
jaw  are  distingiiished  from  cervical  lymph  gland  suppuration  by  the 
history,  the  finding  of  a  purulent  peridental  focus  in  the  mouth,  and 
the  fact  that  the  swelling  of  cervical  phlegTnons  is  all  below  the  lower 
border  of  the  jaw,  while  that  of  periosteal  abscess  is  situated  higher 
and  encroaclies  upon  the  face.     (Compare  Figs.  102  and  103). 

Parulis  of  the  upper  jaw  may  be  mistaken  for  antral  suppuration, 
but  transillumination  of  the  antrum  will  show  that  the  latter  is  intact. 

Acute  osteomyelitis  of  the  lower  jaw  begins  with  more  marked 
symptoms.  Actinomycosis  is,  on  the  contrary,  chronic  and  painless 
from  the  outset,  and  first  infiltrates  the  floor  of  the  mouth. 

Treatment 

Mild  cases  of  periostitis  can  be  treated  by  the  hyiDeremia  method 
(hot  fomentations,  figs  boiled  in  milk  applied  on  the  gum),  but  too 
much  time  must  not  be  wasted.  Many  cases  can  be  incised  through 
the  gum.  Only  when  things  have  gone  very  far,  and  there  is  distinct 
subcutaneous  abscess  must  an  external  incision  be  made,  because  with 
the  latter  there  is  sometimes  a  risk  of  permanent  external  fistula. 
Of  course,  the  treatment  of  the  tooth,  either  conservative  if  it  is  worth 
while  trying,  or  avulsion,  is  of  prime  importance.  However,  it  is  best 
not  to  do  anything  to  the  tooth  during  the  acute  stage  of  the  peri- 
ostitis. 


346 


Figs.  104  t"  107,  inclusive,  reprosciit  v,n-ii>ns  ty|ic<  ol'  osteo- 
myelitis III'  (iirt'ciciit  hones;  either  acute  I  Fig.  105)  m'  chronic 
(Figs.  104,  106,  107). 

The  term  osteomyelitis  is  aiiplied  to  pyoi^enic  jitTections  of  hone 
in  general,  while  in  the  stricter  sense  these  are  divided  into  purulent 
periostitis,  osteitis  and  osteomyelitis.  Since  all  three  parts  of  the 
bone  are  generally  the  seat  of  suppuration  and  clinically  the  process 
can  only  be  localized  to  the  bones  as  a  whole,  and  ns  the  majority 
of  cases  begin  with  infection  of  the  bone-marrow,  the  ii;ime  osteo- 
myelitis is  rational. 

Infection  of  the  bones  may  result,  by  continuity  or  contiguity,, 
from  lesions  of  the  soft  parts,  compound  fraciines,  operations  (this 
was  common  after  amputations  in  the  pre-antiseptie  days) ;  after 
pyogenic  affections  of  the  neighhoring  parts  (subcutaneous  abscess, 
whitlow,  otitis  media).  In  the  latter  cases  the  periosteum  is  first 
infected,  the  cocci  then  invade  the  Haversian  canals  in  the  cortex  and 
contaminate  the  medullary  cavity. 

Infection  may  also,  and  in  fact  does  more  frequently  take  place 
through  the  blood ;  the  medulla  is  then  first  infected,  and  the  suppura- 
tion spreads  to  the  cortex  and  periosteum,  finally  appearing  as  a  sub- 
cutaneous abscess. 

As  in  all  pyogenic  infections,  the  great  majority  of  eases  are- 
caused  by  the  staphi/lococcus  pyogenes  aure)(s;  while  the  staphylo- 
coccus albus,  the  pneumococcus,  the  streptococcus  and  the  Eberth 
bacillus  are  less  frequently  found  in  the  pi;s. 

In  all  pyogenic  affections  in  which  microbes  circulate  in  the  blood 
— and  this  does  not  only  include  such  septicemic  diseases  as  typhoid 
fever,  pneumonia,  or  scarlet  fever,  but  many,  if  not  all,  so-called 
"local"  infections  (see  page  l.")?),  furunculosis,  whitlow,  tonsillitis, 
otitis  media — the  bone  marrow  is  infected  by  cocci,  but  the  power 
of  resistance  of  the  body  is  generally  sufficient  to  withstand  the 
actions  of  the  latter,  which  remain  harmless  till  the  defensive  process 
is  weakened  for  some  reason,  such  as  a  fracture,  overexertion,  ex- 
posure to  cold,  etc.  Osteomyelitis  may  thus  occur  after  injury  to  a 
bone,  even  after  a  slight  contusion.  In  this  case  the  resulting  effusion 
of  blood  favors  further  growth  of  the  cocci  and  leads  to  infection. 
Therefore,  accoi-ding  to  circumstances,  suppuration  of  the  bones  may 
develop  sometimes  directly  after,  and  sometimes  a  long  time  after 
septic  conditions  in  other  organs  of  the  body ;  again,  according  to  the 
number  and  virulence  of  the  bacteria,  it  may  take  an  acute  or  chronic 
form,  with  correspondingly  violent  or  mild  symptoms.    As  usual,  the- 

14r 


process  begins  at  the  seat  of  infection  with  hyperemia  and  exudation; 
then  occur  suppuration,  degeneration  and  regeneration;  these 
processes  assuming  a  special  type  corresponding  to  the  structure  of 
the  bone.  Thrombo-phlebitis  may  develop  and  give  rise  to  metastatic 
infection  by  embolism  in  other  parts  of  the  body  (bones,  endocardium, 
meninges,  etc.). 

As  the  great  majority  of  cases  arise  from  blood  infection,  it  is 
clear  that  the  bones  most' liable  to  infection  are  those  which  are 
most  richly  supplied  with  blood-vessels,  especially  during  their  period 
of  groivth,  when  they  are  most  vascular.  The  diaphyses  of  the  long 
bones  are  thus  most  often  affected  at  their  junction  tvith  the  epi- 
physes. The  lower  ends  of  the  femur  and  radius  and  tibia,  and  the 
upper  ends  of  the  humerus  and  tibia,  are  the  places  of  predilection. 
Osteomyelitis  is  less  common  in  the  short  and  in  the  flat  bones.  It 
is  also  rare  after  the  thirtieth  year.  According  to  the  statistics  of 
Garre,  in  20%  of  the  cases  several  bones  are  affected  simultaneously. 

The  symptoms  of  acute  osteomyelitis  are  more  severe  than  those 
of  any  other  pyogenic  affection.  The  deeper  the  infection,  the  greater 
is  the  virulence  of  the  bacteria.  Bacteria  in  the  bone-marrow  are 
under  greater  pressure  than  in  any  other  tissue,  and  this  increases 
their  virulence.  In  young  individuals  osteomyelitis  often  begins  sud- 
denly after  an  injury,  with  high  fever,  chills,  pains  in  the  joints  and 
severe  constitutional  disturbance.  Pain  on  pressure  on  a  localized 
point  of  the  bone,  or  on  movement,  and  loss  of  function  are  suggestive 
of  an  affection  of  the  bones.  Serous  effusion  soon  takes  place  in  the 
nearest  joint.  Changes  first  appear  under  the  skin  when  pus  collects 
under  the  periosteum.  The  subperiosteal  abscess  appears  as  a 
sharply  defined  fluctuating  swelling  with  hard  borders,  and  the  skin 
over  it  is  tense  and  reddish-blue.  If  the  subperiosteal  abscess  bursts, 
it  gives  rise  to  intermuscular  and  subcutaneous  infiltration,  with  red- 
ness and  swelling  of  the  skin,  and  edema  of  the  soft  parts ;  the  regional 
IjTQphatic  glands  are  swollen  and  painful. 

Although  operation  often  only  reveals  a  subperiosteal  abscess, 
especially  in  children,  in  cases  of  hematogenous  origin  the  cortex 
and  medulla  of  the  bone  are  also  affected.  Involvement  of  the  cortex 
is  shown  by  the  presence  of  yellow  spots  on  the  surface,  which  corre- 
spond to  small  holes  discharging  pus.  After  removal  of  the  cortex, 
the  infected  medulla  shows  reddish-brown  or  yellowish  spots,  which 
may  lead  to  the  formation  of  a  circumscribed  abscess,  or  to  diffuse 
suppuration  in  the  medullary  cavity.  If  the  condition  is  not  recog- 
nized early  and  the  spread  of  infection  checked  by  operation,  separa- 

148 


tion  of  the  epiphyses  or  infeditm  of  llie  joint  may  occur,  or  general 
sepsis  with  death  in  a  few  days.  Jii  extensive  disease  the  whole  hone 
is  whitisli-yellow ;  wliite  from  hloodlessness  due  to  thrombo-phlebitis, 
and  yellow  from  pus  formation.  Numerous  pits  are  seen  from  which 
pus  has  been  dist*harc:cd  under  llie  periosteum. 

The  amount  of  necrosis  i-orresponds  to  the  degree  and  extent  of 
infection.  In  subperiosteal  necrosis  the  destroyed  cortex  and 
medulla  may  regenerate  without  loss  of  substance,  especially  when 
the  pus  has  been  given  an  early  outlet.  If  the  cortex  has  been  for 
some  time  the  seat  of  extensive  purulent  inflammation,  necrosis  must 
result  with  the  formation  of  a  sequestrum.  According  to  the  extent 
of  the  inflammation,  this  necrosis  will  be  limited  to  part  of  the  bone 
or  involve  the  whole  thickness  and  length  of  the  bone  (Fig.  107)- 
In  disease  of  the  cortex  the  sequestrum  is  generally  lamelliform, 
slightly  corroded  and  pitted;  in  disease  of  the  medullary  cavity  the 
sequestrum  is,  to  a  certain  extent,  a  cast  of  the  cavity,  and  trough- 
shaped. 

The  sequestrum  in  osteomyelitis  is  large  and  continuous,  thus 
differing  from  the  sequestra  in  tuberculous  bone  disease,  which  are 
generally  multiple,  small  and  much  corroded.  Complete  necrosis  of 
the  diaphysis  occurs  in  acute  cases  which  have  been  operated  upon 
too  late  and  in  chronic  cases. 

The  sequestrum  becomes  separated  from  the  healthy  bone  by  a 
zone  of  inflammatory  demarcation,  more  or  less  rapidly  according 
to  its  size.  In  extensive  necrosis  the  demarcation  process  may  last 
for  months,  so  that  patients  who  escape  death  from  general  infection 
may  succumb  from  exhaustion,  albuminuria  or  amyloid  degeneration 
of  the  kidneys.  Spontaneous  expulsion  of  the  dead  bone  should  be 
assisted  by  operation  (sequestrotomy). 

The  regenerative  or  osteoplastic  process  goes  hand  in  hand  with 
the  degenerative.  The  suppuration  not  only  causes  necrosis,  but  also 
irritation,  which  stimulates  the  osteogenic  activity  of  the  periosteum. 
This  results  in  thickening  of  the  cortex  at  the  seat  of  necrosis ;  and 
in  cases  of  total  necrosis,  complete  repair  of  the  destroyed  bone  (at 
least  in  young  subjects).  This  irregular  formation  of  new  bone  is 
sometimes  called  the  "sequestral  capsule."  There  are  numerous 
boles  in  this  capsule  where  the  periosteum  has  been  destroyed.  From 
these  holes  ]ius  is  discharged  from  the  zone  of  inflannuatory  demar- 
cation; and  eventually  the  sequestrum,  after  passing  through  one 
of   these   apertures,   is   eliminated   through   a    fistula   in   the   skin 


149 


(Fig.  107).  The  X-rays  are  useful  in  showing  the  extent  of  necrosis, 
and  also  separation  of  the  epiphyses. 

The  whole  process  of  degeneration  and  regeneration  takes  much 
longer  than  in  suppurative  diseases  of  the  soft  parts,  and  the  acute 
stage  is  followed  by  a  chronic  stage  after  the  pus  has  been  evacuated 
spontaneously  or  by  operation.  However,  an  acute  relapse  may  occur 
at  any  time  during  the  chronic  stage,  especially  after  improper  treat- 
ment, or  after  a  trauma. 

Besides  acute  osteomyelitis,  there  exists  a  form  which  is  chronic 
from  the  outset.  In  these  cases  there  is  often  a  history  of  previous 
acute  inflammation  of  the  bone,  and  the  condition  is  really  a  mild 
recurrence,  often  at  the  age  of  puberty,  or  later  in  life ;  hence  bones 
which  have  been  previously  affected  with  os.teomyelitis  must  be 
deemed  as  loci  minoris  resistentice  and  protected  against  injury  and 
overexertion. 

The  clinical  symptoms  in  these  cases  often  resemble  those  of 
chronic  rheumatism,  but  the  pain  is  localized  to  one  bone,  or  some- 
times a  definite  part  of  a  bone.  There  is  often  a  history  of  pyogenic 
disease  in  youth,  and  scars  and  fistulas  may  be  found  in  the  bone 
concerned  or  in  others.  The  affected  bone  is  often  very  tender  to 
pressure  at  certain  points.  In  the  course  of  time  it  becomes  thick- 
ened, and  the  diaphysis  lengthened.  The  growth  in  thickness  may 
be  enormous  at  the  seat  of  disease,  both  the  periosteum  and  cortex 
sharing  in  the  hyperplasia. 

The  changes  in  chronic  osteomyelitis  are  as  follows:  Sometimes 
there  is  a  small  sequestrum  in  the  interior  of  the  bone,  showing  in  an 
X-ray  picture  as  a  clear  spot  surrounded  by  bony  proliferation,  some- 
times a  circumscribed  abscess  in  the  medullary  cavity,  shown  by  the 
X-rays  as  a  round  space  surrounded  by  bone.  If  bony  proliferation 
is  absent  the  X-ray  pictures  resemble  those  given  by  tumors  or  cysts 
in  the  bone.  The  diagnosis  of  chronic  osteomyelitis,  therefore,  may 
be  difficult  when  there  is  no  history  or  evidence  of  former  osteomye- 
litis.   Pain  on  pressure  suggests  the  infectious  nature  of  the  disease. 

If  large  portions  of  the  cortex  and  medulla  are  affected  by  chronic 
osteomyelitis  the  result  is  large  sequestra,  which  seek  a  way  to  the 
surface  in  spite  of  the  considerable  formation  of  new  bone.  In  these 
cases  we  find  numerous  holes  in  the  bony  capsule,  subcutaneous 
abscesses  and  fistulse  (Fig.  106) ;  while  the  whole  bone  is  thickened, 
and  the  X-rays  show  changes  in  the  periosteum,  cortex  and  medulla. 

A  third  form  of  chronic  osteomyelitis  is  limited  to  the  periosteum, 
under  which  a  hyaline  sero-mucoid  fluid  develops,  forming  a  sharply 

150 


doliiKMi,  (liictuatiiiK  swelling  witli  li.ird  lidrdors.  Tliis  liiis  hecii  c-alled 
albuminous  periostitis,  but  is  a  form  of  osteomyelitis.  Staphylococci 
are  present  in  the  fluid. 

All  these  chronic  forms  are  due  to  infection  by  staphylococci  of 
slight  virulence.  Howovor,  every  chronic  osteomyelitis  may  become 
acute,  especially  when  tlic  hones  are  exposed  to  the  eifects  of  over- 
exertion, injury  or  mnssai^c  (wroiift'  diaiiiiosis  or  ostcopalhic  Ireat- 
ment). 

In  the  lons>-  bones,  both  acute  and  chronic  osteomyelitis  may  cause 
disturbance  in  s'J'owth,  shortenini>-  or  lengthening  of  the  limb,  spon- 
taneous fractures  and  pseudarthrosis.  Chronic  osteomyelitic  fistulfe 
may  sive  rise  to  carcinoma  (see  page  23). 

Although  the  great  majority  of  cases  of  acute  and  chronic  oste- 
omyelitis affect  the  long  bones,  both  forms  may  occur  in  the  short 
and  flat  bones;  in  the  skull,  after  compound  fractures,  incised  and 
punctured  wounds ;  in  the  scapula,  pelvic  bones  and  vertebrae ;  in  the 
bones  of  the  face,  after  tooth  extraction.  As  the  cortex  is  thin  in 
these  bones,  there  is  greater  destruction.  Osteomyelitis  of  the  cranial 
bones  may  spread  through  the  diploe  to  half  the  skull,  form  large 
sequestra  of  the  inner  table,  and  epidural  abscess.  In  the  scapula 
the  whole  bone  may  be  destroyed  by  multiple  abscesses  and  sequestra, 
necessitating  complete  removal  of  the  bone  (Fig.  105).  In  osteomye- 
litis of  a  facial  bone,  infection  may  involve  all  the  bones  of  the  face,, 
causing  extensive  destruction  and  consequent  deformity.  Osteomye- 
litis of  the  cranial  and  facial  bones  may  give  rise  to  meningitis. 

In  streptococcic  osteomyelitis  the  pus  is  thinner  and  very  abun- 
dant, and  the  disease  is  more  severe,  like  all  streptococcic  infections. 
In  these  cases  the  skin  usually  shows  erysipelatous  reddening. 

Osteomyelitis  due  to  tyjihoid  bacilli  or  pneumococci  can  be  dis- 
tinguished from  the  other  forms  only  by  the  history  and  bacterio- 
logical examination. 

Diagnosis 

Acute  osteomyelitis,  at  the  onset,  may  be  mistaken  for  any  gen- 
eral infectious  disease  causing  high  fever.  The  only  diagnostic  sign  is 
then  the  finding,  of  tender  points  in  the  juxta-epiphf)seal  region  of 
bones.  Searcli  nmst  always  be  made  for  these  points  in  obscure 
febrile  conditions  of  childi'CMi. 

A  deep  diffuse  phlegmon  r(^senililes  osteomyelitic  abscess. 
Incision  is  the  best  way  to  clear  up  the  diagnosis.     Propulsion  of 

151 


bones  from  below  upward  is  painful  in  osteomyelitis;  and  not  in 
abscess  independent  from  the  bone. 

The  chronic  forms  may  be  confused  with  tuberculous  or  syphi- 
litic osteitis. 

Tuberculous  bone  disease  generally  affects  the  epiphyses,  while 
osteomyelitis  attacks  the  dkiphyses.  Osteomyelitic  fistula  has  hard 
borders  and  bright  red  granulations,  and  passes  directly  to  the  bone, 
while  tuberculous  fistula  has  yelloiv,  slimy  granulations,  irregTilar 
borders  and  an  irregular  course  through  the  deep  parts  (Figs.  125 
and  130).  In  osteomyelitis  the  pus  is  reddish  brown,  in  tuberculosis 
it  is  thin  and  greenish  yellow.  In  doubtful  cases  an  incision  will 
decide  the  diagiiosis;  in  osteomyelitis  the  periosteum  and  cortex  will 
be  found  thickened  and  the  sequestrum-  large  and  continuous ;  in 
tubercular  bone  disease  there  are  multiple,  small  corroded  sequestra. 
In  other  words,  osteomyelitis  tends  to  hyperostosis ;  tuberculosis 
only  to  destruction  of  bone  without  regeneration.  Besides, 
osteomyelitis  generally  has  had  an  acute  onset;  and,  if  dating  back 
to  childhood,  causes  much  more  marked  disturbances  in  tlie  skeletal 
growth. 

Syphilitic  osteitis  is  recog-nized  by  the  anamnesis,  the  Wcisser- 
manii  or  luetin  reaction,  the  pains  more  intense  during  the  night, 
and  tlie  X-ray  findings,  showing  a  diffuse  thickening  of  all  layers 
of  the  bone,  and  a  uniform  dark  shadow  with  irregular  borders,  cor- 
responding to  the  periosteum;  while,  in  osteomyelitis,  dark  shadows 
together  with  clear  spaces  are  shown,  corresponding  to  sequestra  and 
abscesses  respectively.  If  fistulre  form  in  syphilitic  bone  disease 
they  present  the  characteristic  sharp  borders  and  prolific  granulation 
tissue  around  them  (Fig.  122). 

Osteitis  deformans  {Paget' s  disease)  is  characterized  by  affecting 
the  whole  extent  of  both  tibias,  and  by  the  early  appearance  of 
marked  curvature. 

Sarcoma  and  bone-cysts  may  also  in  some  cases  be  difficult  to 
distinguish  from  chronic  osteomyelitic  abscess,  even  by  the  X-rays. 
However,  the  raj^id  increase  in  case  of  sarcoma  soon  dispels  any 
doubts,  and  an  exploratory  incision  is  always  justified. 

Treatment 

Acute  osteomyelitis  calls  for  early  incision  and  opening  of  the 
bone-marrotv  canal,  where  lies  the  primary  focus  of  infection.  This 
is  done  with  a  concave  chisel;  the  bone  marrow  is  scraped  out:  this 

153 


Bockenheimer,  Atlas. 


Tab.  LXXXII 


Fig.  104.     Osteomyelitis  maxillae  inferioris. 


Febman  Company,  New- York. 


does  not  impair  the  iiutriliuii  dT  tlie  bone.    Tlie  wound  is  drained  and 
loosely  packed.    Complete  immobilization  is  necessary. 

In  chronic  osteomyelitis  it  is  best  to  wait  till  the  sequestrum  is 
completely  loosened  and  now  bone  has  begun  to  form  around  it  (X-ray 
examination)  before  performin":  sequestrotomy.  If  there  ai'e  sub- 
cutaneous abscesses  these  must  be  opened.  As  small  sequestra  and 
abscesses  often  cause  considerable  pain,  in  some  cases  the  indication 
is  to  chisel  open  the  bone,  even  if  the  X-rays  show  no  changes.  The 
operation  is  then  troublesome,  as  the  small  sequestrum  or  abscess  is 
often  situated  deep  in  tlie  middle  of  hardened  sclerotic  bone.  Fistula? 
in  chronic  osteomyelitis  must  be  freely  opened  up  and  the  exiiberant 
bone  removed.  The  cavity  remaining  in  the  bone  after  chiselling  must 
be  left  open  and  drained  till  healing  takes  place  from  the  bottom.  Imme- 
diate plugging  of  the  bone  cavity  with  Mosetlg  's  iodof orm-wax  mixture 
renders  good  service  when  all  sequestra  have  been  removed  and  the 
cavity  is  clean.  Even  when  the  filling  mass  is  subsequently  expelled, 
it  has  the  advantage  of  making  the  dressings  easy  and  painless 
(Honians),  while  removal  of  a  packing  from  a  granulating  trough  in. 
a  bone  causes  much  l)leeding  and  sulTering.  Therefore,  as  soon  as 
the  cavity  is  well  granulated,  it  is  scraped,  disinfected  with  peroxide- 
lotion,  dried  with  Hollander's  hot-air  apparatus  till  all  oozing  is 
absolutely  checked,  and  filled  with  a  mixture  of  iodoform,  glycerin  and 
spermaceti.  Whenever  possible,  the  periosteum  should  be  imited 
over  the  plug  and  a  covering  of  skin  made  over  the  cavity.  Strict 
asepsis  is  necessary. 

When  the  whole  diajihysis  of  a  bone  lias  been  destroyed,  bone' 
transplantation  may  be  indicated.  Thus  the  fibula  may  be  used  to- 
replace  a  missing  tibia  (Mc?Jiceii),  or  a  segment  of  rib  to  replace  the- 
lower  jaw,  or  splinters  of  bone  laid  in  the  empty  periostic  sheath  of  a 
humerus.  In  the  first  place,  the  fibula  hypertrophies  and  assumes  the 
function  of  the  tibia;  in  the  latter  cases,  the  transplanted  fragments 
serve  only  as  a  temporary  support  and  a  stinnilant  to  new  bone  for- 
mation, and  slowly  undergo  resorption. 

Frequent  recurrences  in  chronic  osteomyelitis,  with  emaciation, 
albuminuria,  amyloid  degeneration,  etc.,  necessitate  amputation. 
Contractures  must  be  treated  by  oxtonsion  on  a  splint,  ov  when  thev 
cannot  be  extended,  by  resection. 

In  flat  bones  subperiosteal  removal  of  the  whole  bone  is  often 
necessary  (e.g.  scapula,  see  page  155).  This  may  be  followed  by 
complete  regeneration  and  restoration  of  function.  In  osteomyolitis 
of  the  cranium  sequestra  and  epidural  abscesses  must  be  evacuated 

153 


through  a  large  trephine  hole,  which  can  afterward  be  repaired  by 
bone  grafting. 


Fig.  104  shows  chronic  osteomyelitis  of  the  lower  jaw  in  a 
girl  of  19.  It  developed  after  a  tooth  extraction.  It  may  also  result 
from  neglected  cases  of  suppurative  alveolar  periostitis  (Fig.  103). 
A  painless,  diffuse  swelling  of  the  lower  jaw  slowly  developed.  The 
skin  gradually  became  tense,  red  and  edematous :  a  fistula  was  pro- 
duced ;  it  was  opened  up ;  the  discharge  decreased,  but  the  fistula  did 
not  close,  because  necrosis  had  occurred.  Radiographs  showed  a 
diffuse  swelling  of  the  bone. 

A  special  occupational  necrosis  of  the  lower  jaw  is  of  very  par- 
ticular interest,  namely,  phosphorous  necrosis  (phossy  jaw).  It 
occurs  in  workers  in  white  jDhosphorus,  the  vapor  of  which  causes 
"ulceration  of  the  gums,  from  which  buccal  germs  invade  the  peri- 
osteum and  bone.  The  whole  of  the  lower  jaw  becomes  greatly 
swollen.  The  teeth  progressively  loosen  and  fall,  while  the  gums  are 
ulcerated  and  fetid ;  many  patients  succumb  to  pneumonia  or  general 
sepsis.  The  bone  becomes  both  sclerosed  and  brittle.  After  some 
years  (if  the  patient  survives,  the  mortality  is  as  high  as  60%)  total 
necrosis  occurs  with  a  row  of  fistulas  along  the  border  of  the  jaw.  As 
phossy  jaw  cannot  be  prevented,  even  with  the  best  care  of  the  mouth, 
most  countries  (the  United  States  recently)  have  prohibited  the  use 
of  white  phosphorus  in  the  manufacture  of  matches. 

A  similar  condition  observed  in  workers  in  mother  of  pearl  is 
much  less  severe ;  it  undergoes  spontaneous  resolution,  if  the  patients 
change  their  occupation. 

Chronic  osteomyelitis  of  the  lower  jaw,  wliich  is  much  more  fre- 
•quent  than  the  acute  form,  must  be  diagnosed  from  actinomycosis 
(Fig.  116).  In  the  latter  the  swelling  is  situated  in  the  floor  of  the 
mouth  and  in  the  muscles  and  only  later  on  extends  to  the  bones. 

In  the  stage  of  painless  swelling,  chronic  osteomyelitis  may  re- 
semble cystic  adenoma  of  the  jaw.  Malignant  tumors  are  easily  ex- 
-cluded  by  their  rapid  growth. 

The  treatment  is  early  incision ;  later  on,  extraction  of  sequestra. 
In  phossy  jaw  partial  resection  is  useless,  and  owing  to  the  total 
■character  of  the  necrosis,  subperiosteal  resection  of  one  or  both  sides 
of  the  jaw  should  be  performed.  After  this,  regeneration  of  the  jaw 
2nay  take  place  if  the  periosteum  has  been  preserved,  and  relapses 


154 


Hockciiheimcr,  Atlas. 


Tab.  LXXXllI. 


Fig.  105.    Osteomyelitis  sca|nil;ie  acuta. 


Kcbman  Company,  Ncw-N'ork. 


Bockenheimer:  Atlas. 


Tab.  LXXXIV. 


Fig.  106.     Osteomyelitis  humeri  clironica. 


Rebmo.n  Company,  New- York. 


are  avoided.     In  all  cases  of  total  resection  of  the  jaw  hone  ^ral'tiuj 
(see  page  153)  should  be  resorted  to. 


Fig.  105  shows  a  case  of  acute  osteomyelitis  of  the  scapula 

devel(ii)('d  a  few  days  after  au  injury.  A  swcHin.u'  nijpearcd  over  the 
whole  scapular  res'ion  as  far  as  the  supra-clavicular  fossa,  accom- 
panied by  fever  and  chills.  The  skin  became  red  and  mottled,  and 
a  large  fluctuating  subcutaneous  abscess  developed.  The  function 
of  the  shoulder-joint  was  abolished.  An  incision  was  made  and  pus 
evacuated;  the  bone  at  the  seat  of  injury  was  infiltrated  with  pus. 
Plealing  took  place  without  any  necrosis. 

In  osteomyelitis  of  the  scapula,  especially  when  due  to  blood  infec- 
tion, an  abscess  usually  forms  at  the  anterior  border  of  the  scapula, 
as  the  osteomyelitic  focus  in  this  mode  of  infection  is  situated  in  the 
body  of  the  bone.  The  pus  is  at  first  limited  by  the  subscapularis 
muscle;  on  the  other  hand,  the  jiressure  of  the  muscle  causes  rapid 
extension  of  suppuration  in  the  medulla  of  the  bone.  The  abscess 
may  thus  not  be  recognized  till  it  breaks  through  into  the  axilla.  An 
early  symptom  of  osteomyelitis  of  the  scapula  is  painful  effusion 
into  the  shoulder  joint;  on  this  account  it  may  be  mistaken  for  an 
affection  of  that  joint,  the  true  seat  of  disease  only  being  revealed 
after  incision.  In  doubtful  cases  the  anterior  surface  of  the  scapula 
should  be  exposed  by  an  incision  in  the  axilla.  In  most  cases  of 
osteomyelitis  of  the  scapula,  the  wound  does  not  heal  after  incision  of 
the  abscess;  the  occurrence  of  multiple  abscesses  and  necrosis  is  un- 
avoidable, owing  to  the  extension  of  suppuration  through  the  medulla 
of  the  bone.  For  this  reason  the  disease  may  last  for  years.  In 
these  cases,  and  also  in  acute  cases  where  incision  shows  extensive 
destruction  of  the  bone,  subperiosteal  total  extirpation  of  the  scapula 
is  indicated,  taking  care  to  preserve  the  muscular  attachments  and 
the  important  nerves.  (This  is  generally  indicated  in  acute  osteo- 
myelitis of  the  flat  bones,  which  often  gives  rise  to  early  general 
infection.)  After  total  extirpation  of  the  scapula  relapses  are 
avoided,  and  complete  regeneration  of  bone  with  normal  function  is 
l")0ssible  {Bockoiheimer). 


Fig.  106  shows  a  painrul  chih-shaited  swelling  of  the  left  humerus, 
which  gradually  developed  at  the  age  of  puberty,  in  a  patient  who 
had  frequently  suffered  from  tonsillitis  in  childhood.     The  patient 

155 


attributed  it  to  over-exertion  at  liis  work  as  a  blacksmith.  A  year 
after  the  onset,  a  fistula  opened  at  the  posterior  and  external  side 
of  the  arm,  with  hard  borders  and  red  granulations  at  its  orifice.  A 
probe  passed  down  the  fistula  discovered  rough  bone,  denuded  of 
periosteum.  Subcutaneous  abscesses  formed  at  the  front  of  the  arm, 
where  the  skin  was  thin  and  reddened.  Examination  by  the  X-rays 
showed  a  sequestrum,  along  with  new  bone  formation.  Chronic 
osteomyelitis  of  the  diaphysis  of  the  humerus  was  diagnosed.  An 
incision  was  made  down  to  the  bone  in  the  lower  third  of  the  outer 
side  of  the  arm,  avoiding  the  radial  nerve.  The  periosteum  was  de- 
stroyed at  one  place  and  a  hole  was  found  leading  to  a  sequestrum,^ 
which  was  removed  by  carefully  chiselling  the  bone ;  the  cavity  was 
scraped  and  plugged,  and  the  fistulous  track  with  its  hardened  walls 
excised.  The  subcutaneous  abscesses  were  opened  and  scraped.  The 
arm  was  immobilized  for  a  long  time.  Healing  took  place  after  some 
months,  and  the  patient  was  told  to  choose  a  lighter  occupation  in. 
order  to  avoid  recurrence  of  the  disease. 


Fig.  107  shows  acute  osteomyelitis  of  the  tibia  in  a  child,  aged 
9  years,  which  began  with  severe  pain  in  the  leg  and  knee  joint, 
accompanied  by  high  fever  and  chills.  There  was  no  history  of  a 
previous  attack.  A  few  days  before,  the  child  had  received  a  blow  on 
the  tibia.  In  spite  of  the  severe  clinical  symptoms  and  the  marked 
swelling  of  the  knee-joint,  operative  treatment  had  been  neglected, 
and  an  incision  was  made  only  when  a  subcutaneous  abscess  devel- 
oped. Although  the  acute  symptoms  subsided  after  this,  the  swelling^ 
in  the  leg  persisted  and  the  wound  discharged  fetid  pus.  In  a  few 
months  almost  the  whole  shaft  of  the  tibia  became  necrosed.  In 
Fig.  107  the  yellow,  dead  bone  and  the  open  medullary  cavity  with 
slimy  gTanulations  are  clearly  seen.  Between  the  necrosed  and  the 
healthy  bone  are  granulation  tissue  and  pus.  As  the  leg  had  not  been 
properly  fixed,  a  fracture  occurred  at  the  lower  part  of  the  tibia. 
The  general  condition  was  poor.  The  X-rays  showed  that  the  seques- 
trum extended  further  down  and  that  a  thick,  bony  capsule  had 
already  formed  behind  and  at  the  side. 

The  wound  was  enlarged  downward,  the  necrosed  bone  removed,, 
the  cavity  scraped  and  packed,  and  the  leg  immobilized  in  correct 
position  on  a  splint. 

Such  extensive  necrosis  could  have  been  avoided  by  early  chisel- 
ling of  the  bone  and  proper  after-treatment. 

156 


Bockenheimcr,  Atlas. 


Tab.  LX.XXV. 


Pie.  10/.     Osteoinvelitis  tibiae  —  Necrosis  totalis. 


Rcbman  Comp.iiiy,  Ncw-N'ork. 


Bockenheimer,  Atlas. 


Tab.  LXXXVI. 


Fig-.  108.    Infectio  peneralisata. 


Rebman  Conipan}^  New- York. 


Fig.  108  shdws  ;i  metastatic  abscess  of  the  thigh,  one  of  several 
developed  in  the  course  of  an  acute  generalized  infection  arising 
from  a  subcutaneous  whitlow,  whicli  was  insuflieieutly  incised  and 
drained,  and  which  spread  to  the  adjoining  tendon-sheath  and  joint. 
The  temperature  rose  to  106°  F.,  with  chills;  it  remained  high  for  a 
few  days  and. then  became  remittent  during  the  formation  of  several 
metastatic  abscesses,  whidi  i-e(|iiire(l  incision  aiid  contained  tliin  pus 
with  but  few  staphylococci. 

There  also  were  other  general  symptoms:  dry  tongue,  jaundice, 
subdelirium  and  diarrhea.  The  wound  in  the  finger  was  dry  and  un- 
healthy: the  finger  was  exarticulated,  and  it  is  noteworthy  that  bac- 
teria which  had  been  found  in  the  blood  prior  to  this  operation  were 
after  it  no  longer  detected  therein :  a  direct  proof  of  the  origin  of  the 
virulent  microorganisms,  confirmed,  besides,  by  the  improvement  in 
the  general  condition  and  the  checking  of  further  local  inflammation. 
Under  the  influence  of  stimulating  treatment  and  repeated  saline  in- 
jections recovery  took  place  in  a  few  months:  but  for  a  long  time 
afterward  the  pulse  remained  rapid. 

In  every  ])yogenic  condition  there  is  a  slight  degree  of  general 
infection:  even  in  apparentlj'  benign  and  localized  lesions  such  as 
furuncle,  staphylococci  may  be  found  in  the  blood.  This  explains  the 
occasional  occurrence  of  osteomyelitis  after  such  affections,  and  the 
often  existing  disproportion  between  the  local  inflammation  and  the 
general  imiiairment  of  health.  So  that,  strictly  speaking,  there  is  no 
really  localized  infection:  but  the  general  involvement  is  usually  not 
sufficient  to  be  recognized  clinically. 

All  pyogenic  microorganisms  may  l)e  the  source  of  a  general  in- 
fection: pneumococcus,  Ehertli  bacillus,  colon  bacillus,  staplnilococ- 
CHS  and  streptococcus.  From  the  surgical  standpoint  the  last  two  are 
by  far  the  most  important.  Among  putrefactive  bacteria,  the  proteus 
vulgaris  is  the  one  most  frequently  at  fault:  it  causes  a  special  type 
of  sepsis,  but  it  is  seldom  alone:  it  generally  is  associated  with  the 
staphj'lococcus  or  strei)tococcus. 

It  would  lie  very  interesting  to  lie  able  to  distinguisli  in  general 
infection  what  is  due  to  the  bacteria  themselves  and  what  is  due  to 
their  toxins.  There  is  always  simultaneous  bacteriemia  and  toxi- 
neniia;  but  toxins  are  not  easy  to  detect  in  the  blood  owing  to  the 
tendency  they  have  to  become  combined  with  organic  protective 
substances. 


157 


The  part  played  by  the  blood  in  general  infection  is  pre- 
ponderant; dissemination  takes  place  by  small  bacterial  emboli 
(this  must  be  distinguished  from  propagation  by  purulent  thrombi 
in  suppurative  phlebitis) ;  but  we  now  begin  to  appreciate  that  the 
lymph  stream  also  often  has  an  important  role,  and  that  many  metas- 
tatic deposits,  formerly  unhesitatingly  labelled  hematogenous  are 
really  lymphogenous  in  origin. 

The  more  rapidly  virulent  bacteria  invade  the  blood,  the  more 
severe  the  symptoms.  In  very  grave  cases,  the  temperature  rises  to 
104°  or  107° ;  such  cases  generally  cause  death  in  a  few  days  with- 
out clinically  appreciable  metastatic  abscesses.  But  this  does  not 
necessarily  mean  that  there  are  no  anatomical  metastases;  indeed, 
small  foci  are  frequently  found  post  mortem,  especially  in  the  kidney. 
There  is  even  a  form  of  general  infection,  well  studied  by  Brewer, 
Cotton,  Cunningham,  in  which  small  miliary  abscesses  in  a  kidney 
are  the  only  anatomical  lesions  of  a  general  sepsis  that  usually  proves 
fatal  unless  nephrectomy  is  hastily  performed.  In  less  severe  forms, 
the  thermic  ascension  becomes  intermittent  after  the  initial  high 
ascension;  maybe  because  microbes  enter  the  blood  only  inter- 
mittently, or  because  there  are  fewer  of  them.  When  the  body  de- 
fenders conquer  the  bacteria  and  their  toxins,  and  sufficient  anti- 
bodies have  been  formed,  the  temperature  falls.  When  the  invaders 
gain  the  upper  hand,  the  temperature  rises.  If  the  outcome  is  going 
to  be  fatal,  the  longer  the  process  goes  on  the  more  frequent  are  the 
chills  and  the  shorter  are  the  intermissions,  so  that  finally  a  stage 
of  continuous  high  fever  is  reached,  as  in  those  cases,  already  referred 
to,  where  no  remissions  occur  from  the  outset. 

But,  if  the  organism  is  victorious,  the  infection  expands  its  energy 
in  the  formation  of  metastatic  abscesses  in  those  parts  of  the  body 
which  are  specially  adapted  to  absorb  bacteria,  render  them  harm- 
less, and  finally  destroy  them  (subcutaneous  tissue,  serous  cavities, 
peritoneum,  pleura,  joints). 

Staphylococcic  general  infection  has  a  marked  tendency  to  cause 
metastatic  abscesses  (95%  of  cases),  while  the  initial  focus  is  circum- 
scribed. Streptococcic  infections,  on  the  contrary,  as  a  rule  have  no 
localized  initial  focus,  and  in  their  spread  keep  the  same  character 
of  diffuse  processes,  as  they  hardly  ever  cause  metastatic  abscesses. 
Streptococcic  infections  are  more  regularly  fatal  than  staphylococcic, 
precisely  on  account  of  that  same  character.  The  rare  cases  of 
streptococcic  general  infection  that  end  in  recovery  are  those  which 
lead  to  the  formation  of  pus  collections. 

158 


Clinically,  ^oiicral  iiirccliun  i.s  urdiiiarily  acute,  rarely  chronic. 
Acute  general  infection  may  be  i)rimary  or  secondary,  mild  or  severe. 
The  severity  depends  on  the  number  and  virulence  of  the  invading 
niicrol)es,  and  on  the  defensive  power  of  the  body.  The  severest 
forms  develop  so  (|uickly  after  the  local  infection  that  the  latter  remains 
in  the  background;  the  portal  of  entry  may  even  be  unrecognized  and 
the  general  infection  seem  spontaneous;  this  must  occur  most  fre- 
quently after  lesions  of  the  internal  mucous  membranes.  Severe 
forms  are  fre(juently  seen  in  i)hysicians  who  prick  their  fingers  dur- 
ing an  operation  or  an  autopsy  (streptococcus)  :  they  also  result 
from  infection  by  putrefactive  bacteria  (proteus)  or  a  symbiosis; 
both  these  kinds  of  microorganisms. 

In  the  great  majority  of  cases,  however,  general  sepsis  is  of  grad- 
ual onset,  and  arises  from  a  local  primarj'  focus;  but  it  has  often 
reached  an  advanced  stage  before  it  is  recognized.  It  may  occur 
after  a  progressive  extension  of  the  suppuration  in  the  primary 
focus,  but  also  may  arise  ivithoid  further  extension  of  the  latter,  a 
fact  of  prime  importance,  always  to  be  borne  in  mind. 

In  the  hyperacute  forms,  the  symptoms  appear  suddenly,  while, 
in  milder  cases,  there  is  a  premonitory  stage  with  general  disturb- 
ances (insomnia,  loss  of  appetite,  headache,  pain  at  the  seat  of  infec- 
tion). A  frequent  small  pulse  points  to  the  onset  of  general  infection, 
even  before  the  great  thermic  ascension.  This  occurs  suddenly 
(102°  to  106°)  with  chills.  As  already  stated  (see  page  158),  the 
fever  may  remain  continuous  (hyperacute  cases)  or  become  inter- 
mittent or  remittent,  to  become  again  continuous  in  cases  tending 
toward  a  fatal  outcome,  or  to  subside  in  those  terminating  in  recov- 
ery. All  varieties  in  the  temperatui-e  chart  may  be  seen.  Every 
fresh  infection  of  the  blood  is  heralded  in  by  a  rise  of  teniiierature. 
For  example,  after  an  extremity  has  been  amputated  for  progressive 
suppuration,  the  tenqierature  falls;  but  it  may  rise  again  after  a 
time,  showing  that  the  organism  was  already  saturated  with  bacteria 
and  their  toxins  and  that  the  operation  came  too  late  to  save  life. 
However,  under  those  restrictions,  a  fall  in  tem[)erature  after  ex- 
tensive surgical  interference  is  always  a  hopeful  sign.  Hypothermia, 
sometimes  observed  in  very  severe  cases,  is  a  very  grave  omen,  as  it 
indicates  the  utter  collapse  of  the  organism  and  complete  toxemia. 
It  is  noteworthy  that  the  pulse  in  remittent  fever  remains  small  and 
raj)id  during  and  after  the  fall  of  temjierature,  and  during  con- 
vale.scence.  This  shows  how  mucli  llu'  heart  is  affected  in  general 
sepsis,  even  in  curable  foi-ms. 

159 


The  respiration  is  rapid  and  shallow:  it  may  become  stertorous 
when  coma  sets  in,  near  the  end,  in  severe  cases. 

The  tongue  in  general  infection  shows  characteristic  changes ;  at 
tirst  smooth,  dry,  salmon  colored,  it  later  becomes  rough,  fissured 
and  brownish  black.  In  severe  cases  the  teeth  also  are  dry  and  coated 
with  sordes.  The  conjunctives  are  yellow,  and  in  severe  cases  the 
jaundice  (hematogenous  icterus)  may  be  general.  There  is  profuse 
sweating  and  uncjuenchable  thirst. 

These  symptoms  are  the  only  ones  in  case  of  general  sepsis  of 
internal  origin  (e.g.  after  pylephlebitis),  but  when  the  portal  of  entry 
is  a  preexisting  suppurating  wound,  the  latter  exhibits  local  changes, 
the  appearance  of  which  is  fairly  characteristic :  the  wound  becomes 
painful  and  edematous;  the  granulations  look  unhealthy  and  flabby; 
the  discharge  of  pus  is  much  lessened  and  replaced  by  a  scanty,  dirty, 
often  fetid  secretion;  the  surface  of  the  wound  becomes  dry  and 
often  covered  by  a  diphtheroid  membrane  (Fig.  101).  Pns  reten- 
tion, necrosis,  extension  of  suppuration,  lymphangitis  and  adenitis 
are  often  concomitant  signs.  In  infection  by  putrefactive  bacteria 
(Fig.  109)  there  are  bullae  in  the  infiltrated  skin  and  crepitation  due 
to  the  formation  of  gas,  and  bubbles  of  gas  in  the  secretion.  In 
order  not  to  overlook  these  signs,  suspicious  wounds  must  be  fre- 
quently dressed.  Another  frequent  sign,  more  common  in  advanced 
stages,  is  septic  secondary  hemorrhage  in  the  wound,  one  of  the  most 
dreaded  scourges  of  preantiseptic  surgery,  and  which  is  due  to  vas- 
cular degeneration. 

The  gastro-intestinal  canal  is  severely  affected:  there  may  be 
hematemesis,  bilious  vomiting  and  uncontrollable  diarrhea.  The 
skin  is  pale  and  cold  and  may  present  various  types  of  erythema, 
scarlatiniform,  morbilliform,  erysipelatous,  or  vesicular  eruptions 
and  purpura.  Almost  all  the  internal  organs  are  saturated  with 
bacteria  and  their  toxins.  Hence  the  nephritis  (evidenced  by  albu- 
minuria and  casts),  the  meningitis,  pleuritis,  pericarditis  and  endo- 
carditis that  are  seen- so  frequently.  Nephritis  is  even  constant.  The 
spleen  is  enlarged,  and  so  may  be  the  thyroid  gland. 

In  the  advanced  stages,  the  patients  become  subdelirious,  then 
delirious,  finally,  and  generally,  unconscious.  Just  before  the  end, 
if  not  comatose,  the  patient  may  have  maniacal  excitation  followed  by 
collapse. 

In  streptococcic  general  infection,  there  is  nearly  always  suppu- 
ration in  the  joints :  in  staphylococcic,  in  the  bones.  Bacterial  emboli 
carried  to  the  capillaries  can  and  do  disseminate  the  infection  to  all 

,160 


organs  of  tlio  limly  (particiiljirly  the  luiig-.s,  liver,  lioart  and  kidiiej-s). 
Embolus  ol'  tlie  ceiilral  arlcry  of  the  retina  causes  i)ano|)lillialinia. 
Even  if  the  involvement  of  the  central  organs  escapes  clinical  de- 
tection at  first,  overshadowed  as  it  is  by  the  more  noisy  and  tlireat- 
ening  signs  of  generalized  infection,  it  may  become  prominent  after- 
ward, after  an  apparent  cure,  and  residual  foci  of  old  septicemise,  long 
quiescent,  arc  fi'cqiifiiily  the  cause  of  grave  trouble  subsequently 
(supimrativc  nephritis,  ciiddcarditis,   ])l(Mirisy,  or  pneumonia). 

Multiple  metastatic  abscesses,  as  already  said,  are  much  more 
frequent  in  staphylococcic  infectious:  they  may  remain  cold  and 
painless  and  (•inilaiii  hut  few  haetoria,  as  was  the  case  in  the  abscess 
shown  in  Fig.  108. 

The  chronic  forms  of  sepsis,  which  occur  after  long-standing 
fistula;,  suppuration  and  necrosis  (particularly  osteomyelitis)  are 
characterized  by  their  gradual  development  and  mild  symptoms. 
Many  cases,  however,  are  fatal  from  heart  failure  or  albuminuria 
{amyloid  degeneration),  or  a  chronic  form  may  become  acute.  In 
chronic  cases,  the  remission  periods  are  long,  and  metastatic  abscesses 
are  tlie  rule.  Recovery  may  take  place  after  removal  of  the  primary 
cause,  Init  convalescence  is  very  slow. 

Prognosis 

It  depends  on  the  general  condition  of  the  subject.  Young  and 
robust  individuals  may  survive  acute  forms;  older,  weakened,  dia- 
betic subjects  do  not,  barring  exceptions. 

It  depends  also  on  the  nature  of  the  infecting  host.  Streptococcic 
infections  are  the  most  redoubtable  of  all:  staphylococcic  infections 
are  more  likely  to  end  in  recovery.  Pneumococcie  infections  are  the 
mildest  of  all. 

It  clinically  depends  on  the  type  of  the  disease:  hyperacute 
eases,  with  continued  fever,  are  always  fatal ;  subacute  remittent 
cases,  with  abscess  formation,  are  less  serious;  chronic  cases  recover, 
unless  so  much  time  is  wasted  before  the  necessary  surgical  interfer- 
ence that  irretrievable  damage  is  done  to  the  internal  viscera. 

Abscess  formation  is  always  a  hopeful  sign;  so  is  generally  a 
decrease  of  the  number  of  bacteria  circulating  in  the  blood,  with  this 
qualification,  that  in  some  cases  such  a  decrease  is  followed  by  an 
increase  in  the  clinical  severity  of  the  toxic  symptoms. 

Always  remember,  after  recovery,  the  possible  existence  of  en- 
capsulated metastatic  foci  or  inconii>lotoly  healed  septic  infarcts. 


liU 


Diagnosis 

The  clinical  picture  of  general  infection,  though  many-sided,  does 
not  generally  leave  room  for  doubt,  especially  if  there  is  a  known 
primary  focus. 

Direct  demonstration  of  the  bacteria  in  the  blood,  by  blood  culture, 
clinches  the  diagnosis.  Streptococci  are  more  easily  demonstrated  in 
the  blood  than  staphylococci. 

Blood  cultures,  and  the  different  agglutination  reactions,  estab- 
lish the  nature  of  the  infection,  and  differentiate  typhoid  fever,  pneu- 
monia, miliary  tuberculosis,  all  diseases  which  closely  resemble  gen- 
eral infection,  because,  in  fact,  they  are  general  infections,  but  caused 
by  .other  microbes  than  those  at  fault  in  the  two  great  ty^ses  of  sur- 
gical sepsis. 

Acute  rlieum,atism  is  soon  recognized  by  its  exclusively  articular 
involvement,  and  its  changeable  localizations. 

Severe  erysipelas  may  somewhat  resemble  general  infection: 
sometimes  the  diagnosis  is  only  a  distinction  without  much  differ- 
ence, because  there  is  often  general  infection  in  those  severe  cases. 


Everything  that  promotes  the  strength  of  the  body  is  indicated 
(nourishing  diet,  tonics),  as  is  the  stimulation  of  faltering  organs 
(caffeine,  strychnia).  Saline  infusions  restore  tone  to  the  circula- 
tory system  and  effectively  help  in  the  elimination  of  toxins.  No 
antipyretics  should  be  given,  as  they  are  useless,  and  simply  depress 
the  heart.  The  high  temperature  is  best  reduced  by  tepid  or  cool 
sponging. 

Locally,  if  there  be  a  wound,  frec[uent  dressings  are  necessary: 
no  antiseptics  should  be  used.  Hot  wet  dressings  induce  active 
hyperemia  of  the  part. 

Alcohol  or  ether  dressings  have  been  sometimes  very  efficient  in 
grave  infections  of  the  limbs.  All  retention  of  pus  should  be  sup- 
pressed. In  iDrogressive  infection  of  the  limbs  amputation  should 
not  be  too  long  delayed. 

In  impending  general  infection  from  thrombo-phlebitis,  ligation, 
or  even  excision,  of  the  veins  should  be  resorted  to  (see  page  123). 
Metastatic  abscesses  must  be  opened  early,  according  to  the  rules 
governing  incisions  of  abscesses  in  the  region  where  they  are  situ- 
ated.   Joint  resection  is  often  necessary. 

The  serum  treatment  of  general  sepsis  has  been  considerably 
improved  during  recent  years.    However,  the  results  are  not  always 

162 


Bockenheimer,  Atlas. 


Tab.  LXXXVII. 


Rebman  Company,  New- York. 


as  sntisfnotory  ;is  ooul<l  ho  desired.  Nevertheless,  as  an  injection  of 
antistreptot'oeeie  j)olyvaIeiit  serum  can  do  iiiudi  .i(ood,  and  cannot 
liarin,  it  is  always  indicated  to  use  it  early  in  strei)tococcic  septicemia. 
Antistai^hylococcic  vaccines,  very  useful  in  chronic  stai)liylococcic 
infections,  are  uncertain  in  their  results  in  general  infection.  The 
injection  of  collargol  is  not  much  used  now.  Other  metallic  colloidal 
(gold,  selenium)  salts  are  reported  by  some  authors  as  having  a 
favorable  action. 

As  the  development  of  an  abscess  generally  is  a  hopeful  occurrence 
followed  by  marked  improvement,  it  has  been  attempted,  particularly 
in  puerjjeral  infection,  to  determine  the  formation  of  an  abscess  by 
a  subcutaneous  injection  of  turpentine  {Fochier).  This  has  sometimes 
proved  successful  in  ajiparently  absolutely  hopeless  cases. 

Strengthening  the  body  resistance  during  convalescence  of  re- 
covered cases  is  always  essential.  The  tonic  treatment  must  be  kept 
up  for  months. 


Fig.  109  shows  a  very  striking  example  of  a  hyperacute  septic 
condition,  wliich,  in  preantiseptic  days,  was  a  not  infrequent  compli- 
cation of  crushed  wounds  and  amputations,  and  which  is  possessed 
of  more  names  than  any  other  surgical  affection ;  a  few  being  gaseous 
phlegmon  or  gangrene,  fulminating  gangrene,  bronzed  eri/sipelas, 
malignant  edema,  emphiise}natous  gangrene,  acute  purulent  edema, 
etc.  It  was  one  of  the  first  conditions  to  disappear  when  antisepsis 
began;  to-day  it  is  a  rarity,  almost  a  "laboratory"  disease. 

The  characteristic  feature  is  rapid  putrefaction  under  the  influ- 
ence of  gas-forming  bacteria.  TN'hich  are  the  latter  is  not  known  with 
certainty,  but  they  belong  to  the  anaerobic  group.  Pasteur's  septic 
vibrio,  the  bacillus  emphysematosus  and  the  proteus  vulgaris  are 
the  bacteria  found,  generally  associated  with  pyogenic  microbes, 
staphylococci  and  cliiefiy  streptococci.  It  is  even  thought  that  such 
a  symbiosis  is  necessary  for  the  development  of  gaseous  gangrene, 
one  kind  being  responsible  for  the  gangrene,  the  other  for  the  sep- 
ticemia. 

Typical  gaseous  gangrene  is  sometimes  seen  after  trifling  lesions 
of  the  skin  (in  Fig,  109,  two  small  abrasions  of  the  fingers  with  a 
meat  knife) ;  but  it  usually  follows  (or,  rather,  followed)  crushing 
injuries  and  compound  fractures,  especially  when  soiled  with  earth 
and  ground  dirt.  It  occurs  chiefly  on  the  extremities  or  on  the  back  in 
connection  with  bedsores. 

163 


A  similar,  but  less  acute  and  fatal,  condition  is  seen  in  operative 
wounds  on  the  rectum,  when  infected  by  feces ;  in  the  penis,  scrotum 
and  perineum,  from  lesions  of  the  urethra  with  so-called  "extravasa- 
tion of  urine"  (which  is  not  at  all  an  infiltration  of  urine,  as  was 
thought  formerly,  but  a  diffuse  gangrenous  phlegmon  of  urinary 
origin;  the  serosity  is  that  of  inflammatory  edema,  and  does  never 
contain  urea) :  in  the  neck,  after  operations  on  the  esophagus  and 
pharynx.  All  these  wounds  are  deep  and  anfractuous,  thus  giving 
anaerobic  bacteria  a  favorable  ground  to  grow  on. 

The  wound  becomes  dry,  coated  and  fetid,  and  extensive  swelling 
rapidly  spreads  from  it  on  all  sides.  The  wound  discharge  is  brown- 
ish or  greenish,  fetid,  and  mixed  with  necrotic  shreds  of  tissue. 
Severe  pain,  extreme  anxiety  and  agitation,  later  on  delirium  and 
frequent  pulse  indicate  the  onset  of  general  infection,  which,  from  the 
beginning,  is  of  the  severest  type  and  progresses  very  rapidly  with- 
out any  fever,  or  at  least  without  the  high  fever  we  are  accustomed 
to  find  in  general  sepsis.  The  advance  of  the  gaseous  infiltration 
has  sometimes  been  visible  to  the  naked  eye:  in  a  few  hours  large 
portions  of  the  body  are  affected  by  the  rapid  formation  of  gas. 

The  circulation  is  obstructed  by  the  great  pressure  of  gas  in  the 
tissues.  The  skin  of  the  extremities  becomes  pale  and  cold  and  pre- 
sents brown  and  green  spots,  bluish  livid  streaks  of  lymphangitis  and 
punctiform  hemorrhages.  Small  vesicles  filled  with  dark  fluid  then 
appear,  which  later  on  become  larger:  finally  the  whole  epidermis 
of  the  affected  part  is  raised  and  underneath  it  is  offensive,  dirty 
fluid.  In  other  places,  the  skin  is  reddish-brown  (bronze  color),  hard 
and  infiltrated.  There  is  no  formation  of  circumscribed  fluctuating 
collections  of  fluid,  but  the  tissues  are  saturated  with  fetid,  sanious, 
gas-filled  serosity. 

On  pressure  tissues  give  the  characteristic  crepitation  of  cutane- 
ous emphysema.  The  infiltration  is  best  seen  after  incision:  the 
tissues  cannot  be  distinguished  from  each  other ;  muscles,  fascia  and 
periosteum  are  transformed  into  sodden,  homogeneous,  greenish 
shreds.  If  the  medullary  cavity  of  a  bone  is  opened,  it  is  filled  with 
sanious  fluid.  Sometimes  circumscribed  cavities  containing  fluid  and 
gas  are  found  under  the  skin,  and  such  accumulations  may  give  rise 
to  enormous  bulgings  near  the  root  of  the  limbs  and  where  the  sub- 
cutaneous tissue  is  loose.  Pressure  of  gas  may  cause  gangrene  of 
the  peripheral  parts  of  the  extremities,  and  the  appearance  is  similar 
to  that  given  by  the  putrefaction  of  a  corpse  (Fig.  109).  The 
lymphatic  glands  are  swollen  and  painful;  the  veins  are  thrombosed; 

164 


fiunlly,  tlie  arterial  walls  are  destroyed:  hence  severe  hemorrhage. 
A  sauious  fluid  fills  tlio  iioip^hhoring  joints. 

The  emphysema  may  cover  very  large  areas :  for  instance,  the 
•whole  back  or  the  abdomen,  or  a  whole  limb.  Death  occurs  from 
genei'al  infection  or  edema  of  the  glottis  or  mediastinitis.  Bacteria 
are  not  usually  found  in  the  blood. 

Despite  the  most  heroic  measures,  the  prognosis  is  fatal  in  true 
gaseous  gangrene  in  more  than  95%  of  cases:  within  thirty-six  hours, 
three  or  four  days  at  the  utmost.  A  few  cases,  in  young,  strong  indi- 
viduals, have  a  slightly  slower  evolution:  to  those  belong  the  very 
small  minority  of  cases  ending  in  recovery.  In  post-operative  diffuse 
gaseous  phlegmon  the  prognosis  is  not  so  bad;  it  is  decidedly  better 
in  extravasation  of  urine,  provided  it  be  properly  treated. 

Diagnosis 

The  ultrarapid  evolution  of  the  disease,  the  necrosis  of  all  tissues, 
the  crepitation  distinguish  gaseous  gangrene  from  hemorrhagic 
bullous  erysipelas  (Fig.  91)  and  anthrax  (Figs.  112  and  113).     A 

bacteriological  examination  is  always  useful. 

Treatment 

A  particularly  careful  disinfection  of  all  crushing  injuries  and 
compound  fractures  by  tincture  of  iodine  is  the  best  prophylaxis. 

When  gaseous  gangrene  is  detected,  it  is  always  too  late  to  save 
the  part.  In  a  limb,  amputation  must  be  performed  forthwith,  and 
high  above  the  limit  of  crepitation.  Numerous  free  incisions  with 
the  thermocautery  in  infiltrated  tissues,  when  amputation  is  not 
possible,  and  moist  dressings  with  hydrogen  peroxide  deprive  the 
anaerobic  bacteria  of  the  medium  necessary  for  their  existence. 

This  treatment,  applied  to  urinary  infiltration,  often  leads  to  re- 
covery, and  it  is  often  surprising  how  enormous  defects  of  sloughed 
skin  on  the  penis  and  the  scrotum  heal  up  quickly  and  nicely. 

In  gaseous  phlegmon  of  the  neck,  a  preliminary  tracheotomy  is 
necessary  before  operation. 

In  the  case  represented  in  Fig.  109,  despite  free  incision?;  and 
exartieulation  of  the  shoulder,  on  the  third  day  the  patient  died. 


165 


Fig.  110  shows  an  acute  lymphadenitis  of  the  left  inguinal 
region,  consecutive  to  an  excoriation  of  tlie  skin  of  the  thigh,  which 
has  already  scabbed  over.  Tlie  lymph  glands  act  as  barriers  between 
initial  lesions  (pyogenic  or  cancerous)  and  the  rest  of  the  body.  In 
case  of  pyogenic  bacteria  coming  from  a  primary  focns,  the  glands 
stop  them  and  destroy  them,  unless  they  be  too  virulent  or  numerous, 
in  which  case  the  glands  become  themselves  affected.  Lymph  gland 
inflammation  is  non-suppurative  or  suppurative.  Besides  the 
cervical  glands  (see  Figs.  102  and  114),  the  axillary  and  the  in- 
guinal groups  are  the  most  frequently  involved.  Suppurative  ade- 
nitis of  the  groin  is  called  bubo. 

To  the  superficial  ingTiinal  lymph  glands  go  the  cutaneous  lymph- 
vessels  of  a  very  wide  area,  lower  limb,  perineum,  scrotum,  penis, 
anus  and  abdominal  wall  below  the  navel.  To  the  deeper  group  go 
the  deep  lymphatics  of  the  thigh  and  the  lymphatics  of  the  gians  penis 
in  the  male,  and  of  the  clitoris  in  the  female. 

It  was  foi'merly  thought  that  each  subdivision  of  this  territory 
of  the  superficial  ing-uinal  glands  corresponded  to  a  special  group 
of  glands,  always  the  same.  Eecent  studies  have  disproved  this  idea ; 
there  is  no  rigid  systematization.  However,  but  only  as  giving  a 
relative  indication,  and  no  absolute  certainty,  it  may  be  stated  that 
the  lymphatics  of  the  lower  limbs  go  to  the  loiver  group  of  inguinal 
glands ;  those  of  the  scrotum  and  genitals  to  the  internal  glands  of 
both  the  lower  and  upper  groups:  those  of  the  perineum  in  the  upper 
glands  of  both  same  groups;  those  of  the  anus  in  the  upper  and 
external  gToup ;  those  of  the  umbilicus  and  abdominal  wall  to  the 
upper  group.  This  may  give  a  general  indication  as  to  where  to  look 
for  the  origin  of  any  given  suppuration. 

Any  portal  of  entry  for  bacteria  within  this  territory  may  cause 
bubo;  hence  the  frequency  of  the  latter.  Excoriations  of  all  kinds, 
ulcers,  ingTowing  toenails,  lesions  of  the  genitals  (particularly  soft 
chancre  and  gonorrhea)  are  the  most  frequent  causes.  Chancroidal 
bubo  may  contain  the  Ducrey  bacillus,  but  more  commonly  is  the  re- 
sult of  a  secondary  infection;  so  is  the  bubo  of  gonorrhea  generally 
due  to  balanitis  and  balano-posthitis. 

The  acute  forms  are  very  painful  and  prevent  motion  of  the  limb. 
The  skin  becomes  red  and  is  at  first  movable  over  the  inflamed  and 
tender  glands  (pure  adenitis)  ;  but  it  gradually  becomes  infiltrated 
and  bluish  in  color  while  the  glands  become  matted  together  (peri- 
adenitis) ;  finally  diffuse  suppuration  may  set  in  (Fig.  110  and  also 
Fig.  102).  Then  there  are  chills,  fever,  and  constitutional  disturb- 
ance.    In  other  cases,  the  inflammation  is  better  localized  (see  Fig. 

166 


Bockenheiiiiei",  Atlas. 


Tab.  LXXXVIli. 


Pig.  110.     Lympliadenitis  iiiguiiialis  diffusa  (Bubo) 


Rcbman  Company,  Ncw-^'ork. 


114).  Tlie  skill  bocomes  thin,  niid,  if  not  inoifiCfl  previously,  ulcerates 
niul  the  pus  is  discharged,  al'tcr  whirh  the  pain  subsides,  but  healing 
is  often  very  slow,  espcci.-iljy  in  cliiincrnidal  luibo.  This  is  probably 
due  to  autoiuoculatiou  nl'  the  wdiind  Uy  the  Ducrey  streplobacil- 
lus.  W'hcti  such  ;iii  inl'ci'l ion  ilncs  imt  take  place,  i)i_iiuin;il  iidciiitis 
heals  Just  abdiil  as  (|nickly  as  any  njlicr  adenitis. 

Diffuse  suppurative  adenitis  causes  necrosis  not  only  of  the  glands 
themselves,  but  also  of  the  periglandular  tissue  and  even  of  the  sub- 
cutaneous tissue.  Moreover,  burrowing  abscesses  may  develop  in 
remote  places  (in  the  pelvis  after  bubo,  in  the  retropharj'ngeal  glands 
after  cervical  abscesses).  Again  general  infection  is  possible, 
though  rare. 

In  chronic  forms,  iuliaunnatoi'y  symptoms  are  abscul.  'IMicrc  only 
is  a  slightly  painful  enlargement  of  the  glands  which  subsides  after 
some  time,  leaving,  however,  a  fibrous  hyperplasia  of  the  nodes. 
Chains  of  small,  chronically  inflamed  lymph  glands  in  the  groin  are 
exceeclingh'  common. 

Diagnosis 

Acute  lymphadenitis  is  easily  diagnosed  from  its  situation.  Other 
conditions  have  already  been  discussed  (see  Fig.  102  and  page  144). 

A  femoral  hernia  may  be  mistaken  for  a  bubo,  especially  if  in- 
flamed. This  must  always  be  remembered,  as  incision  in  hernia  might 
be  unpleasant  to  patient  and  physician.  Plowever,  the  inflamma- 
tory symptoms  of  the  skin  are  absent  in  hernia,  and  in  bubo  the  nodes 
are  generally  multiple. 

Tuberculosis  of  the  inguinal  glands  and  cold  abscess  is  distin- 
guished by  the  torpid  evolution,  without  pain  or  fever,  the  thin, 
greenish  pus,  and  the  undermined  edges  of  the  fistula,  if  present. 

Adenitis  of  the  axilla  may  be  mistaken  for  hidrosadenitis  (see 
page  128),  but  the  latter  are  multiple  small  tumors  inlaid  In  the  skin, 
and  not  subcutaneous. 

Chronic  adenitis  must  be  differentiated  from  syphilitic  adenitis 
(see  page  179),  tuberculosis  and  cancerous  involvement.  The  in- 
guinal glands  are  involved  in  cancer  of  the  anus. 

Treatment 

Cleanliness,  the  early  treatment  of  the  causal  disease,  and  the 
avoidante  nf  cauteyization  in  too  old  chancroids  (which  only  dams 
back  the  virulent  secretion  and  decidedly  favors  the  development  of 
bubo,  besides  doing  absolutely  no  good  to  the  chancroid  itself)  con- 
stitute the  prophylaxis  of  venereal  bubo. 

167 


Suppurative  adenitis  must  be  incised  as  early  as  the  presence  of 
pus  is  ascertained ;  in  the  case  of  chancroids,  great  care  Inust  be  taken 
to  prevent,  if  possible,  the  inoculation  of  the  Ducrey  bacillus,  but 
often  the  latter  is  in  the  pus  itself:  injections  of  a  10%  emulsion  of 
iodoform  in  glycerin  are  useful.  Frequent  dressings  are  needed. 
Patients  are  best  kept  in  bed.  Silver  nitrate,  Peru  balsam  are  em- 
ployed to  stimulate  the  always  slow  granulation  process. 

In  case  of  large  glands  causing  pain,  or  of  multiple  fistulije,  the 
best  is  to  excise  all  diseased  glands,  taking  care,  however,  to  insure 
a  good  hemostasis  and  not  to  be  too  radical  in  the  removal  of  con- 
nective tissue ;  as  bilateral  extirpation  of  the  inguinal  glands  is  some- 
times (Fig.  71)  followed  by  lymphatic  stasis  and  elej)hantiasis. 

Inunctions  with  iodine  preparations,  ichthyol  or  mercurial  oint- 
ment may  prove  useful  to  bring  about  the  resolution  of  chronic  non- 
suppurative inguinal  adenitis. 


Fig.  Ill    shows   a  case  of  gonorrheal  arthritis  of  the  wrist 

in  a  woman. 

Gronorrheal  arthritis  is  the  commonest  systemic  manifestation  of 
gonorrhea,  its  frequency  being  estimated  to  about  1%  of  the  treated 
cases  of  urethral  gonorrhea.  It  is  much  more  frequent  in  men  than 
in  women,  and  particularly  frequent  in  children,  if  the  smaller  num- 
ber of  cases  observed  in  the  latter  be  taken  into  consideration. 

The  focus  of  absorption  in  the  male  is  the  posterior  urethra. 
Gronorrheal  rheumatism  does  not  occur  in  simple  anterior  ure- 
thritis. It  is  particularly  frequent  in  posterior  urethritis  compli- 
cated by  prostatitis  and  vesiculitis.  Indeed,  seminal  vesiculitis  has 
been  blamed  for  the  most  obstinate  cases  {Fuller).  This  influence 
of  the  prostate  and  seminal  vesicles  as  a  safe  harbor  for  gonocoeci 
in  gonorrheal  rheumatism  is  confirmed  by  the  relative  infrequency 
of  the  affection  in  women. 

There  are  no  parallel  variations  between  the  intensity  of  the  local 
urethral  process  and  the  systemic  manifestations  of  gonorrhea.  The 
worst  case  of  gonorrheal  tenosynovitis  (akin  to  arthritis)  I  ever  saw 
was  in  a  young  man  with  a  very  mild  anterior  urethritis  (first  attack) 
treated  frorn  the  outset,  and  apparently  almost  cured  in  three  weeks. 
Frequency  denoting  the  posterior  involvement,  and  fever  and  the 
tendon-sheath  metastasis  appeared  suddenly  and  simultaneously. 
But,  even  if  such  unpleasant  surprises  are  possible,  it  goes  without 
saying  that  every  fresh  infection,  every  relapse  of  an  incompletely 
cured  gleet,  increases  the  chances  of  gonorrheal  rheumatism,  espe- 

168 


Bockenheimer,  Atlas. 


Tab.  I.XXXIX. 


Fig.   111.     Ariliritis  i^xiiioniioica  plilcLiiiumosa. 


Rtbnian  Company,  Ncw-Voik. 


c'ially  ill  lliosc  who  li;i\c  .iliciily  siilTcrci]  from  the  latter.  Repurrent 
attacks  ai'c  not  inri-eijiiciil,  and  arc  ulivnys  possible  as  long  as  the 
individual  lunlxvs  gonococci. 

Gonorrlical  rliciunatism,  as  a  rule,  is  not  as  iwlyarlicular  as  ordi- 
nary rlieiiniatisiii ;  it  ordinarily  is  iiioiiodiiiiiildr  and  strikes  large 
joints.  The  knee  is  Ity  far  the  iiiosl  rrc(|iicntly  ai'fectefl,  next  come 
the  ankle,  foot  and  wrist,  tint  no  joinl  is  iiMimiiie,  and  several  may 
be  involved. 

Anatomically,  the  lesions  are  liinllcd  In  tin'  joint,  or  affect  hnlli  the 
joint  and  the  houe.  Of  course,  tlie  latter  cases  have  a  much  more 
unfavorable  prognosis  in  so  far  as  ultimate  damage  to  the  structures 
and  function  is  concerned.    ' 

The  fluid  in  the  joint,  in  case  of  arthritis,  may  be  serous,  fibrUious 
or  purulent.  The  fibrinous  type  is  the  one  met  with  oftenest,  sup- 
purative arthritis  being  rare  and  generally  caused  by  a  mixed  infec- 
tion. The  tendency  to  periarticular  infiltration  is  more  marked  than 
in  other  types  of  arthritis.  The  inflammation  is  destructive  in  the 
severe  cases,  commonly  it  is  hyperplastic,  hence  the  tendency  to 
stiffening,  limitatio)i  of  function  and  anchylosis,  which  is  the  most 
serious  danger  of  gonorrheal  arthrilis,  even  in  its  mild  forms. 

This  danger  is  intensified  when  primary  bone  lesions  exist,  as  then 
there  is  destruction  of  bone,  and  irregular  proliferations  of  the  irri- 
tated and  thickened  periosteum.  Prognosis  as  to  function  is  then 
very  doubtful. 

Acute  gonorrheal  arthritis  is  very  sudden  in  its  onset,  and 
attended  by  severe  pain,  preventing  any  movement  of  the  aflfected 
joint.  In  a  few  hours  the  soft  parts  become  infiltrated  and  ede- 
matous, the  infiltration  is  more  or  less  limited  to  the  region  of  the 
joint,  or,  frequently,  spreads  to  the  neighboring  muscles  and  tendons. 
The  skin  is  red  and  tense  (Fig.  111).  In  severe  cases  there  is  high 
fever  and  complete  loss  of  function.  In  chronic  cases  there  usually 
are  aching  pains  in  the  joint  before  the  arthritis  becomes  evident. 

When  the  efTusion  is  merely  serous  or  sero-fibrinous  and  limited 
to  the  joint,  resorption  generally  takes  place  in  one  or  two  weeks  and 
restitutio  ad  integrum  is  complete.  But  in  the  more  common  form 
of  fibrinous  arthritis,  with  marked  periarticular  infiltration,  the  out- 
come is  not  so  favorable.  In  the  joint  are  produced  fibrous  bands 
which  limit  motion.  When  there  is  a  bone  involvement  (which  is 
primary,  and  not  due  to  the  extension  of  the  articular  inflammation, 
as  heretofore  believed;  this  is  clearly  established  by  early  X-ray 
examination),  cartilaginous  and  even   bony  anchylosis  is  the  nmst 

169 


frequent  termination.  Destruction  of  the  capsule  may  cause  sub- 
luxation or  dislocation,  and  prolonged  immobility  leads  to  muscular 
atrophy. 

In  the  rarer  forms  of  purulent  arthritis,  fever  is  very  high,  gen- 
eral symptoms  are  marked,  the  skin  is  red  and  the  swelling  tense. 

Chronic  forms  are  less  noisy  in  their  clinical  expression,  but 
multiple  relapsing  arthritis  may  reduce  the  patients  to  a  deplorable 
condition,  as  they  often  cannot  walk  or  use  their  arms. 

Diagnosis 

Gonorrheal  rheumatism  supervening  during  an  acute  attack  of 
gonorrhea,  or  relapsing  cases,  are  geiaerally  easily  diagnosed,  be- 
cause the  caiisal  relation  is  evident. 

But  it  may  be  exceedingly  doubtful  when  occurring  a  long  time 
after  the  acute  stage,  when  the  uncured  chronic  condition  has  been 
overlooked  or  forgotten.  In  every  case  of  arthritis,  the  possihilitij  of 
gonorrheal  infection  must  he  borne  in  mind,  and  investigations  made 
to  find  whether  or  not  the  patient  harbors  gonococci.  The  comple- 
ment-fixation test  {Schwartz  and  O'Neil)  will  render  signal  ser- 
vices in  this  respect.  A  complete  examination  of  the  genital  tract 
is  indispensable  (two  or  three  glass  tests,  rectal  digital  examination  of 
the  prostate  and  seminal  vesicles,  smears  and  cultures).  X-ray  exam- 
ination also  must  be  performed.  It  is  particularly  interesting  to  find 
from  the  outset  whether  there  is  a  zone  of  rarefaction  in  the  bone, 
as  this  has  a  direct  bearing  on  the  prognosis  (see  above). 

Actite  rheumatism  is  more  polyarticular,  wanders  more  from 
joint  to  joint,  involves  the  smaller  joints,  and  yields  promptly  to 
salicylic  treatment,  while  the  latter  hardly  influences  gonorrheal 
rheumatism. 

Purulent  gonorrheal  arthritis  must  be  diagnosed  from  other  joint 
suppurations  by  the  anamnesis  and  bacteriologic  examination  of  the 
fluid  withdrawn  by  tapping.  However,  this  proves  often  sterile  in 
all  types  of  gonorrheal  arthritis. 

Syphilitic  arthritis  may  be  very  hard  to  distinguish  from  chronic 
gonorrheal  cases;  but  the  nocturnal  character  of  the  pain,  which 
is  decreased  by  exercise,  the  Wassermann  or  luetin  reactions,  the 
previous  history,  and  X-ray  examination  may  solve  the  problem. 

Tuberculous  arthritis  would  be  considerably  easier  to  ditfer- 
entiate,  at  least  in  its  ordinary  forms  (see  Figs.  125,  126,  127). 


170 


Treatment 

Tlie  best  i  realm  cut  of  u^diiorriicil  .irtliiitis  is  prophylaxis  by  the 
correct  treatiiieiit  of  all  ciises  of  uniinnhca,  liowevor  triflint^  tliey 
may  look,  especially  to  patients. 

The  milder  serous  forms  recover  after  two  weeks  of  rest  in  bed 
and  immobilization  of  the  joint  in  a  si^lint  apparatus  or  a  light  plaster 
of  Paris  cast.  Bier's  passive  hyperemia  greatly  aids  to  resori:»tion. 
Active  hot-air  hyperemia  is  contrarndicated  in  this  stage  as  it  in- 
creases pain.  Rest  must  be  complete  and  active  treatment  of  the 
gonorrhea  must  be  kept  up  as  long  as  there  are  any  inflammatory 
symptoms,  but  as  soon  as  complete  subsidence  of  the  latter  has  been 
obtained,  gentle  massage  and  passive  and  active  motion  must  be 
started.  This  treatment  brought  about  complete  restoration  of  func- 
tion in  four  weeks,  in  the  case  depicted  in  Fig.  111. 

Besides  rest  and  passive  hyperemia,  serum  or  vaccine  treatment 
is  the  only  thing  really  efficacious  against  gonorrheal  rheumatism. 
Serum  seems  to  act  better  in  the  acute  and  subacute  stages,  while 
vaccines  are  far  superior  in  the  chronic  forms  (ScJimidt). 

Purely  arthritic  forms  require  a  more  prolonged  immobilization 
than  those  of  primary  bone  involvement,  in  which  passive  motion 
must  be  begun  early  in  order  to  avoid  complete  loss  of  function  and 
anchylosis. 

Chronic  forms  are  often  very  obstinate.  Vaccine  (not  serum) 
treatment  does  not  give  as  regTilar  an  improvement  as  in  the  acute, 
recent  cases.  It  benefits  (particularly  as  regards  pain)  40  or  50% 
of  the  cases.  Active  hyperemia  (hot-air  baking,  2S0°-300°)  has  given 
me  better  results  than  passive  congestion.  Massage  and  passive 
motion  are  indicated  when  there  is  no  acute  exacerbation. 

Arthrotomy  and  washing  of  the  joint  are  resorted  to  only  in  the 
suppurative  cases;  that  is,  comparatively  rarely,  especially  if  the 
serum  and  rest  treatment  has  been  properly  applied  from  the  outset. 

Starting  from  the  idea  that  the  seminal  vesicles  are  the  "thorn" 
that  keeps  chronic  cases  relapsing,  Fuller  in  inveterate  gonorrheal 
arthritis  performs  vesiculotomy  and  drainage.  He  claims  excellent 
results. 


171 


Fig.  112  shows  a  case  of  malignant  pustule  of  the  face,  which 
developed  in  a  tanner  after  a  slight  abrasion  of  the  skin.  Fig.  113 
shows  the  same  case  a  few  weeks  after  infection. 

Malignant  pustule  (external  anthrax  or  malignant  edema)  is 
the  inoculation  lesion  of  a  general  infectious  disease  caused  by  the 
anthrax  hacillus,  that  is,  the  germ  of  cattle  fever.  The  bacilli  and 
spores  are  found  in  the  alimentary  canal  of  animals  (horses  and 
cattle) ;  also  in  damp  soil  on  which  these  animals  graze,  and  in  the 
skin,  fur  and  excrements  of  the  infected  animals.  They  are  trans- 
mitted to  man  either  directly  from  diseased  cattle,  pasture  or  soil 
(farmers),  or  by  the  skins  and  furs  of  infected  animals  (butchers, 
tanners,  wool  sorters,  furriers,  workers  in  horsehair,  etc.).  Anthrax 
in  cities  is  exclusively  an  occupational  disease,  the  reporting  of  which 
is  compulsory  in  many  States  (New  York,  far  instance). 

The  disease  may  also  be  transmitted  by  flies  feeding  on  the 
corpses  of  dead  animals,  and  by  earthworms.  Besides  external 
anthrax,  there  is  also  an  internal  anthrax,  resulting  from  the  inocu- 
lation of  the  virus  in  some  point  of  the  alimentary  canal,  by  ingestion,, 
or  from  the  inhalation  of  spore-containing  dust  (pulmonary  anthrax; 
this  form  is  less  common). 

The  bacilli  may  remain  localized  at  the  seat  of  infection  or  may 
enter  the  blood-stream  and  give  rise  to  metastatic  foci  in  other  places, 
while  their  toxins  play  only  a  subordinate  part. 

External  anthrax  is  observed  particularly  on  the  face  and  neek^ 
small  abrasions  of  the  skin  being  the  portals  of  entry.  The  infection 
may  be  conveyed  to  the  mouth  by  the  finger  and  the  spores  may  thus 
be  inhaled  or  swallowed,  and  give  rise  to  internal  anthrax. 

Anthrax  of  the  skin  has  a  very  characteristic  appearance.  A 
small,  red  spot  first  appears,  with  fever,  and  often  chills;  this  de- 
velops into  a  small  blister  with  a  yellowish  or  turbid  liquid  content 
where  the  specific  bacilli  are  found.  This  is  the  malignant  pustule,. 
which  ruptures  and  is  replaced  by  a  scab.  At  the  same  time,  the 
surrounding  skin  becomes  green — a  sign  of  commencing  necrosis. 
Early  necrosis  of  the  skin  (Fig.  112)  is  one  of  the  salient  features 
of  anthrax.  Around  the  central  eschar,  and  forming  a  ring  around 
it,  develop  a  number  of  vesicles  absolutely  similar  to  the  original 
vesicle;  outside  of  this  ring  the  tissues  become  infiltrated  as  in  car- 
buncle, and  still  more  peripherally  there  is  a  zone  of  edema,  which 
can  assume  huge  dimensions  in  regions  where  the  subcutaneous  tissue- 
is  loose.  The  redness  of  the  skin  extends  rapidly  and  irregularly, 
resembling  erysipelas.  The  newer  vesicles  rupture ;  others,  still  more- 
peripheral,  appear,  and  also  rupture ;  after  each  rupture  the  necrosis- 

172 


iockenlieimer,  Atlas. 


Tab.  X( 


Fi"-.  112.    Anthrax         l^ustula  maligna. 


Rcbni.nn  Company,  New-York. 


Bockenheimer,  Atlas. 


Tab.  XCI. 


Fig.  113.    Anthrax  —  Necrosis. 


Rebman  Company,  New- York. 


of  the  skin  extends  more  nnd  more.  Tims,  nlways  presenting:  its  three 
conceutrica!  zones — centriil  necrosis,  middle  vesicular  rin<;,  external 
infiltration — the  mali.n'iiant  pustule  s))reads  uiilil  it  lias  reached  quite 
a  large  size  (Fig  113). 

i^esides  the  above-mentioned  symptoms,  there  are,  if  the  ])ustule 
is  located  on  the  limbs,  lymphangitis,  adenitis  and  mixed  infection 
abscesses.  General  symptoms  are  always  marked,  fever,  chills,  head- 
ache, rapid  pulse.  General  infection  with  dry  tongue,  jaimdice, 
diari'hea,  enlargement  of  the  spleen  occurs  in  about  25%  of  the  cases. 
Death  may  result  from  collapse  in  a  few  days. 

External  anthrax  has  a  less  unfavorable  progiiosis  than  intci-iial, 
except  when  located  on  the  face,  where  it  has  all  the  dangers  of  facial 
septic  conditions,  and  besides  may  spread  to  the  mouth  and  the  di- 
gestive tract.  In  the  milder  forms  of  anthrax  septicemia,  metastases 
are  caused  by  emboli  in  the  skin,  lungs,  liver,  brain,  etc.;  hence 
pleurisy,  pneumonia,  ulcers,  peritonitis,  meningitis,  -which  are  gen- 
erally fatal. 

Internal  anthrax  usually  aiTects  the  intestines  (buccal  infection) ; 
it  causes  hemorrhagic  ulcerations  of  the  small  intestine  with  tendency 
to  gangrene.    The  mortality  is  80%. 

Pulmonary  anthrax  clinically  resembles  pneumonia.  The  mor- 
tality is  90%,  from  pulmonaiy  edema  and  pleurisy.  Internal  anthrax 
may  cause  secondary  metastatic  foci  in  the  skin.  Internal  and  ex- 
ternal anthrax  may  coexist. 

Diagnosis 

A  typical  malignant  pustule,  with  its  central  eschar,  surrounded 
by  a  ring  of  vesicles  and  a  zone  of  hard  infiltration,  is  not  ditiRcult 
to  diagnose,  especially  when  the  occupation  of  the  patient  is  one  of 
those  exposing  to  anthrax  infection. 

However,  pyogenic  or  putrefactive  infections  of  a  virulent  ty]ie 
(Fig.  109)  and  hemorrhagic  bullous  erysipelas  (Fig.  91)  may 
cause  the  formation  of  vesicles  on  the  skin  and,  therefore,  be  mis- 
taken for  anthrax;  but  the  course  is  different,  there  is  no  necrosis  of 
the  skin  and  the  three  zones  do  not  exist. 

Glanders  also  cause  blister  formation  and  gangrenous  ulceration, 
but  the  characteristic  infiltration  of  anthrax  is  absent.  In  all  cases 
where  there  is  the  least  suspicion,  a  bacterial  examination  of  the 
fluid  of  the  bullae  m\;st  be  made  forthwith.  The  anthrax  bacillus  has 
pathognomonic  "appearance :  it  shows  as  immobile  rods  with  sharp, 
angular  corners,  often  arranged  in  a  row  of  long  chains.  In  the 
centre  of  the  rods  are  clear  spaces  corresponding  to  spores,  which 
are  very  resistant  to  desiccation  and  heat. 

1:3 


Finding  the  bacillus  in  the  stools  of  suspected  cases  of  intestinal 
anthrax  is  ijractically  the  only  way  of  making  the  diagnosis,  just  as 
finding  it  in  the  blood-stained  sputum  of  a  pulmonary  case  is  the  only 
means  of  ditferentiating  it  from  ordinary  pneumonia  or  pleurisy. 


Prophylaxis  consists  in  strict  supervision  of  trades  in  which 
there  is  a  danger  of  anthrax  infection.  Skins  should  be  disinfected 
and  workingmen  taught  hygiene.  Preventive  vaccination  of  cattle 
against  anthrax  was  the  first  ever  applied  (Pasteur). 

A  rather  large  percentage  of  the  not  too  severe  cases  of  malignant 
pustule  recover  spontaneously,  under  expectant  treatment  consisting 
simply  in  isolation,  complete  rest,  local  applications  of  ointments  to 
prevent  auto-inoculation,  and  tonics  to  raise  the  defensive  power  of 
the  body.  Such  a  treatment  was  successfully  applied  in  the  ease 
represented  in  Figs.  112  and  113.  But  systematic  abstention  cannot 
be  made  a  rule. 

When  the  malignant  pustule  is  still  small  and  situated  on  the 
limbs,  it  may  be  destroyed  with  the  thermocautery.  When  it  has 
reached  a  large  size  and  spreads  rapidly,  its  progress  may  be  checked 
by  subcutaneous  injection  in  the  infiltrated  peripheral  zone  of  iodine 
solutions  so  as  to  form  a  ring  around  the  pustule.  Such  injections 
are  repeated  several  times,  as  needed.  Tincture  of  iodine  is  extremely 
powerful  against  the  anthrax  bacillus. 

When  the  infection  does  not  extend  any  more,  but  has  left  a  large 
eschar  (as  in  Fig.  113,  where  the  leathery,  blackened,  necrosed  skin, 
firmly  adherent  to  the  underlying  tissues,  is  demarcated  by  a  zone  of 
pus  and  slimy  granulations  from  the  surrounding  skin,  which  is  still 
red  and  infiltrated),  no  attempt  should  be  made  to  remove  said  eschar 
by  sharp  spoon  or  knife,  lest  we  start  a  fresh  outbreak  of  infection. 
It  is  therefore  allowed  to  separate  gradually,  and  the  defect  is  re- 
paired by  a  plastic  operation,  if  need  be. 

Sdavo's  serum  may  sometimes  prove  useful  in  anthrax. 

Fig.  114  shows  an  abscess  of  the  lymphatic  glands  behind  the 
ear.  The  cause  is  pediculosis  of  the  scalp  (note  the  gluing  of  the 
hair  and  the  punctiform  deposits  (nits)  on  them).  Pediculosis, 
throiigh  scratching,  is  frequently  the  origin  of  eczema  and  adenitis, 
suppurative  or  non-suppurative.  In  the  case  shown,  the  submaxillary 
lymph  nodes  were  enlarged  and  tender  on  pressure.  The  abscess  was 
incised. 

(See  Figs.  102  and  110). 

174 


Bockenhcimer,  Atlas. 


Tab.  XCII. 


Rcbniaii  Company,  NL■w■-^'ork. 


Bockenheimer,  Atlas. 


Tab.  XCIII. 


Fig.  116.    Aktinomykosis  progressiva. 


Rebman  Company,  New- York. 


CHRONIC  INFECTIONS 

Fig.  115  shows  a  case  df  incipient  actinomycosis  of  the  i-liofk  in 
an  (lid  couiitrywonian.  Fig.  116  slmws  ,i  c.-isc  of  extensive  actino- 
mycosis iif  tlie  neck  in  a  vdiiiii^  countryman. 

Aclinoniycosis  is  a  (iini|iaratively  rare  disease,  due  to  infection 
by  the  raji-fnvgus,  which  is  found  in  corn,  straw  and  Hour.  Jlence  the 
greater  frequency  of  actinomycosis  in  country  peoi)le,  farmers  and 
millers.  In  countrymen  who  have  the  habit  of  chewing  corn  or  straw, 
infection  takes  place  through  a  carious  tooth  (case  of  Fig.  115) 
or  through  the  parotid  duet.  xVctinomycosis  of  tlie  buccal  cavity, 
mucosa,  tongue,  lower  jaw  {lumpy  jaw),  pharynx  and  neck  constitute 
a  great  majority  (56%),  while  lung  actinomycosis  claims  13%,  and 
abdominal  actinomycosis  21%  of  all  cases. 

Actinomycosis  of  the  buccal  walls  presents  itself  as  a  string^", 
nodular  infiltration,  which,  by  becoming  confluent,  produces  a  swell- 
ing of  woody  hardness.  Acute  inflammatory  symptoms  are  absent. 
The  skin  becomes  bluish-red  wlion  tlie  infiltration  extends  through 
the  cheek  or  into  the  neck  (Figs.  115  and  116).  The  infiltration 
spreads  gradually  into  the  neighboring  tissues  and  its  progress  is 
unlimited.  Simultaneously  the  centre  of  the  mass  softens,  ulcerates 
and  a  complex  fistula  is  formed,  which  discharges  through  several 
openings  pus  containing  characteristic,  pin-head  size,  yellow  bodies 
(in  -which  the  microscope  readily  detects  the  fungms). 

There  is  much  induration  around  the  fistuhp:  this  often  causes 
retention  of  pus,  and,  in  the  case  shown  in  Fig.  115,  the  pressure  of 
the  induration  on  the  malar  bone  had  been  sufficient  to  cause  gan- 
grene of  a  patch  of  skin.  Granulation  tissue  is  scanty,  yellowish-red 
in  color,  and  rapidly  disintegrated.  Large  abscesses  may  result  from 
mixed  infection:  the  yellow  bodies  are  then  often  absent,  the  fungus 
being  destroyed  by  the  pus  cocci. 

In  actinomycosis  of  the  cheek,  there  always  is  an  external  fistula. 
If  the  infiltration  involves  the  masticatory  muscles,  there  is  some 
trismus  (case  of  Fig.  115).  The  fungus  may  invade  the  bones  and 
give  rise  to  enormous  tumors.  If  the  upper  jaw  is  involved,  the 
fungus  may  reach  the  base  of  the  skull  and  lead  to  meningitis  or 
cerebral  abscess.  If  the  tongue  is  infiltrated,  its  motion  is  hindered. 
If  the  pi-ocoss  im])licat('s  the  base  of  the  tongue  or  the  fauces,  dys- 

1T5 


pliagia,  and  later  dyspnea,  develop.  In  these  cases  abscesses  form, 
which  generally  discharge  through  cervical  fistnlse  and  give  rise  to 
secondary  actinomycosis  of  the  skin,  more  common  than  primary  skin 
actinomycosis. 

Lung  actinomj'cosis  may  result  from  direct  inhalation  or  sec- 
ondary buccal  involvement.  The  symptoms  are  very  much  like  those 
of  tuberculosis.  However,  pleural  and  thoracic  involvement  lead  to 
abscess  formation  and  external  fistula.  The  disease  may  spread  to 
the  pericardium,  the  vertebrae,  the  diaphragin  and  the  abdominal 
cavity.  .  The  patient  becomes  exhausted  from  empyema  and  multiple 
burrowing  abscesses.  Adequate  drainage  is  next  to  impossible  to 
insure,  so  that  relapses  are  very  common. 

Intestinal  actinomycosis  chiefly  affects  the  ileo-eecal  valve,  where 
it  causes  a. hard,  tumor-like  infiltration,  which,  if  markedly  developed, 
may  produce  intestinal  obstruction.  Thence  the  disease  may  spread 
in  all  directions,  and  bring  about  the  formation  of  an  external  fistula. 

Diagnosis  and  prognosis 

When  actinomycosis  is  visible  externally,  the  diagnosis  usually  is 
not  difficult:  the  wood-like  infiltration,  multiple  fistulsE,  yellow  granu- 
lations and  yellow  bodies  in  the  pus  are  pathognomonic.  Of  course, 
finding  the  ray  fungais  under  the  microscope,  a  very  simple  thing, 
absolutely  clinches  the  diagnosis.  It  must  be  done  in  all  doubtful 
cases. 

As  microscopical  examination  is  so  easy  and  so  conclusive,  it  will 
sufiice  to  mention  the  conditions  which  at  first  sight  might  resemble 
actinomycosis. 

Lupus,  tumors  of  the  cheek  and  tongue,  cold  abscesses,  gummata, 
woody  phlegmon  of  the  neck  might  be  mistaken  for  cervico-facial 
actinomycosis,  or  vice  versa;  tuberculosis  of  the  lung  for  lung 
actinomycosis. 

Infiltration  of  woody  hardness  between  the  ribs  is  always  sug- 
gestive of  actinomycosis.  The  latter  must  always  be  borne  in  mind 
in  presence  of  a  hard,  diffuse  tumor  of  the  ileo-cecal  region,  the  other 
possibilities  being  tuberculosis,  cancer,  or  dense  old  adhesions. 

The  prognosis  is  fairly  good  in  cervico-facial  lesions ;  two-thirds 
of  the  patients  recover  under  appropriate  treatment.  It  is  very  bad 
in  lung  actinomycosis:  recoveries  are  exceptional.  It  is  slightly 
better  in  abdominal  actinomycosis. 


176 


Bockenheimer,  Atlas. 


Tab.  XCIV. 


c 


O 


bi3 


txo 


Rebman  Company,  New-York. 


Treatment 

Wlien  surgic.il  rciiuival  is  feasible,  it  is  the  best  treatment  (re- 
section of  the  gut  ill  ileocecal  actinomycosis).  AVhen  not,  incision 
and  scraping  of  the  al)scesses  and  sinuses,  and  frequent  dressings 
should  be  resorted  to,  with  intermittent  courses  of  treatment  with 
potassium  iodide,  40  to  (JO  grains  a  day.  X-rays  liave  proved  useful 
in  Stelivugon's  hands.  General  treatment,  tonics,  ai-senic,  sustaining 
diet,  are  very  important,  as  exhaustion  is  the  chief  danger  in  chronic 
eases. 


Fig.  117  shows  a  case  of  marginal  glossitis,  also  called  geo- 
graphical tongue.^  This  is  a  rare  affection,  cJiieHy  seen  in  infants, 
but  also,  occasionally,  in  adults,  and  characterized  by  gja'ate,  gray, 
figures  involving  the  borders  and  dorsum  of  the  tongue.  The  chief 
lesion  is  a  hyperkeratosis  of  the  lingual  papilhi?.  The  patch  begins 
as  a  scaly  macule  and  spreads  peripherally,  while  the  centre  again 
becomes  normal. 

The  nature  of  marginate  glossitis  is  unknown.  Kaposi  and  Parrot 
considered  it  as  syphilitic,  and  Fournier  as  parasyphilitic;  but  the 
actual  consensus  of  opinion  is  against  any  such  relationship.  It  may, 
pei'haps,  result  from  gastro-intestinal  disturbances  {Stehcagon). 
The  course  is  chronic,  and  the  lesions  may  continue  indefinitely. 

Diagnosis  and  treatment 

Marginate  glossitis  is  chiefly  of  interest  on  account  of  the  possi- 
bility of  its  being  mistaken  for  other  ling-ual  conditions.  Leucoplakia 
(Figs.  8  and  9)  gives  an  altogether  different  picture.  So  does 
tertiary  syphilitic  glossitis  (Fig.  119). 

The  treatment  consists  simply  in  bland  mouth  washes,  swabbing 
with  tincture  of  myrrh  and  attention  to  the  gastro-intestinal  tract. 

'Compare  Figs.  U7,  118,  119,  with  Figs.  6,  7,  8,  9. 


177 


SYPHILIS 

Figs.  118  to  123,  inclusive,  represent  various  syphilitic  lesions. 
Fig.  118  shows  an  initial  sclerosis  on  the  tongue;  the  others  show 
gummatous  conditions,  that  is,  they  belong  to  a  much  later  period 
of  the  evolution  of  the  disease. 

SyiDliilis  is  a  specific,  chronic,  infectious  disease  due  to  the  in- 
vasion of  all  the  body  tissues  by  the  Spirocheta  pallida,  a  spirillum 
described  by  Schaudinn  and  Hoffmann  in  1905,  recently  cultivated  by 
NogucM,  and  which  has  now  been  found  in  all  syphilitic  products  and 
also  in  the  blood  in  both  acquired  and  hereditary  syphilis. 

Infection  takes  place  through  slight  abrasions  of  the  skin  or 
mucosae.  In  most  cases,  the  origin  is  direct  and  genital,  but  extra- 
genital direct  contamination  is  possible  in  any  point  of  the  body,  and 
is  very  far  from  uncommon.  Indirect  contagion  through  towels, 
drinking  glasses,  cigars,  pipes,  shaving  brushes,  razors,  is  also  fairly 
frequent.  Congenital  syphilis  is  the  result  of  infection  of  one  or  both 
of  the  progenitors. 

The  spirocheta  pallida  has  a  marked  predilection  for  the 
intima  of  blood  vessels.  Endarteritis  and  the  perivascular  arrange- 
ment of  round-cell  infiltration  are  constant  characteristics  of  all 
syphilitic  lesions,  from  the  earliest  to  the  latest. 

Acquired  syphilis  begins  by  an  incubation  period  of  three  to  five 
weeks,  followed  by  the  development  at  the  inoculated  point  of  an 
initial  lesion  {hard  chancre),  that  is,  a  circumscribed,  hard,  painless 
infiltration  of  the  skin  or  mucosa.  The  chancre  forms  a  hard  nodule 
movable  over  the  underlying  structures.  It  is  a  flat  erosion  Avith  an 
even,  dark-red,  surface,  regular  smooth  borders  (Fig.  118)  and  a 
characteristically  indurated  base.  The  chancre  can  be  situated  in 
any  point  of  the  body:  the  genital  zone  (prepuce,  glans  penis,  labia) 
is.  naturally  most  commonly  affected;  but  the  tongue  (Fig.  118), 
lips,  tonsils,  fingers,  and  nipple  are  other  frequent  locations. 

Every  case  of  acquired  syphilis  begins  by  a  chancre,  except  very 
rare  instances  of  direct  blood  inoculation  (physicians  pricking  a 
finger  during  an  operation).  But  in  a  good  proportion  of  cases  (10% 
according  to  some  authors)  the  chancre  is  overlooked. 

Without  treatment,  the  chancre  heals  in  a  few  weeks  (much  quicker 
under  the  influence  of  treatment),  leaving  no  scar  if  no  secondary 

178 


infection  has  taken  place,  because  the  erosion  of  tlie  chancre  is  pnreh) 
epider»iic  and  does  not  involve  the  corium.  Suppuration  only  takes 
place  when  the  chancre  is  infected  by  pus  cocci ;  sometimes  the  chancre 
becomes  phagedenic.  , 

Mixed  chancre  is  due  to  simultaneous  infection  by  the  spirocheta 
pallida  and  the  Ducrey  bacillus:  owing  to  the  shorter  incubation 
period  of  the  latter,  the  chancroid  develops  first,  and  induration 
appears  later,  sometimes  when  the  soft  chancre  has  already  healed  up. 

From  the  chancre,  its  initial  focus,  the  spirocheta  pallida  invades 
the  whole  body.  First,  about  two  weeks  after  the  appearance  of  the 
chancre,  the  regional  lympli  gknids  become  enlarged  and  form  hard, 
painless,  movable  swellings,  which  never  suppurate,  except  in  mixed 
infections;  later,  the  adenopatJig  becomes  general,  and  what  has  been 
called  the  "secondary  explosion"  takes  place. 

It  is  characterized  by  general  constitutional  disturbances  similar 
to  those  of  constitutional  infectious  diseases,  foremost  among  which 
are  anemia,  fever,  and  especially  pains  in  the  muscles,  hones  and 
joints,  and  headache;  all  these  painful  symptoms  are  more  marked 
at  night,  are  not  influenced  by  analgetic  drugs,  but  yield  to  specific 
treatment.  Headache  is  due  to  arteritis  of  the  cerebral  arteries:  it 
is  an  evidence  of  early  involvement  of  the  nervous  system;  but  there 
are  many  cases  without  headache  in  which  the  nervous  involvement  is 
proved  by  the  lymphocytosis  of  the  cerebro-spinal  fluid,  and  the  in- 
creased proportion  of  albumin  in  the  latter.  Nervous  involvement 
exists  in  67%  of  the  cases  of  syphilis  during  the  secondary  period 
(Bavaut). 

Externally,  the  secondary  period  is  heralded  in  by  an  eruption. 
A  rose-red  macular  rash  (roseola)  develops  on  the  abdomen  and 
thorax.  Later  on  various  eruptions  develop  (secondary  syphilides), 
the  most  common  of  which  is  an  eruption  of  flat,  rounded,  reddish- 
brown  or  ham-colored  papules  on  the  trunk,  face  and  limbs.  On  the 
forehead  these  ]iapules  form  the  so-called  "corona  veneris."  On 
the  genital  organs  and  around  the  anus  these  papules  become  sodden 
and  white,  and  are  known  as  condylomata  lata,  w^iicli  are  liable  to 
ulcerate.  In  some  cases  pustular  eruptions  form,  and  in  severe  or 
neglected  cases  the  inistules  become  ulcers  covered  with  limpet- 
shaped  crusts  (syphilitic  rupia).  Acneiform  eruptions  are  common 
on  the  scalp,  and  scaly  or  psoriasiform  syphilides  on  the  palms  and 
soles.  Most  secondary  eruptions  disappear  without  leaving  any 
trace,  but  the  ulcerative  forms  (rupia)  leave  pigmented  scars,  which 
later  on  become  white  in  the  cei^^^re. 

179 


The  macular  rash  is  toxic  in  origin;  all  the  other  syphilides  are 
round-celled  infiltrations,  similar  to  the  roimd-celled  iniiltration  of 
primary  sclerosis,  similar  also  to  the  infiltration  of  tertiary  gummata. 
These  infiltrations  never  tend  to  permanent  connective  tissue  organi- 
zation, but  to  involution  and  resorption.  They  always  spread  periph- 
erally, while  the  centre  heals  up. 

Clinically  syphilitic  eruptions  are  characterized  by  their  reddish- 
brown  or  ham  color,  their  tendency  to  polymorphism,  to  occur  in 
groups,  and  to  be  arranged  in  circinate  figiires  (more  marked  in  the 
later  stages  of  the  disease  and  in  the  negro  race  [Foic] ) ,  the  absence 
of  subjective  symptoms,  itching  or  pain. 

The  mucous  membranes,  especially  of  the  mouth,  are  affected  by 
papular,  erosive  or  ulcerative  syphilides,  which  are  known  as  mucous 
patches.  These  develop  on  the  tonsils,  fauces,  tongue,  and  inside  the 
lips  and  cheeks,  in  the  form  of  grayish-white  patches  or  streaks,  with 
a  red  border.  Later  on  they  may  become  eroded  or  ulcerated  in  their 
central  parts,  and  then  appear  as  red  erosions  with  a  gray  border. 
In  early  secondary  syphilis  the  tonsils  and  fauces  may  be  acutely 
swollen  (syphilitic  angina),  but  more  often  there  is  a  dark-red  colora- 
tion of  the  tonsils,  fauces  and  soft  palate. 

In  secondary  syphilis  there  often  is  a  special  alopecia  areata. 
The  loss  of  hair  is  sometimes  due  to  acneiform  syphilides  of  the  scalp, 
but  more  often  api)ears  without  any  apparent  lesion.  The  nails  are 
sometimes  affected  with  onychia  or  paronychia. 

The  secondary  peiiod  lasts  until  the  symptoms  of  an  active 
general  infection  disappear,  that  is,,  from  a  few  months  in  most 
cases,  to  one  or  two  years.  Then  outward  signs  may  keep  lack- 
ing forever :  perhaps  in  a  few  cases  there  is  a  complete  cure, 
but  of  the  latter  there  is  no  proof,  and  we  have  no  criterion  to 
judge  of  it.  In  a  rather  large  number  of  cases  the  disease  is  simply 
latent,  as  evidenced  by  the  positive  result  of  the  Wasserniann  test, 
and  by  the  subsequent  development  of  parasyphilitic  conditions, 
chiefly  of  the  nervous  system.  In  some  other  cases  there  occur  cir- 
cumscribed or  diffuse  infiltrations,  not  differing  in  any  essentials 
from  the  round-celled  infiltration  of  the  other  periods  of  syphilis  and 
called  gummata.  The  latter  are  considered  (somewhat  arbitrarily) 
as  the  characteristic  feature  of  the  stage  of  syphilis  designated  as 
tertiary.  Gummata  may  appear  in  all  stages  of  the  disease,  but  they 
are  rare  during  the  secondary  period,  and  the  older  the  infection 
becomes,  the  less  chances  of  seeing  gximmata  develop.  With  the 
ordinary  mercurial  treatment  of  but  few  years  ago,  a  great  majority 

180 


Bockenlieimcr,  Atlas. 


Tab.  XCV. 


< 


O 


in. 


Rcbman  Company,  New- York. 


of  the  treated  cases  remained  free  from  gummatous  lesions.  With 
the  newer  methods,  still  l)etter  results  may  be  coulidently  expected. 

In  gummata,  the  tendency  to  siimiltaneoiis  periplieral  extension 
and  central  regression  exists  as  in  all  syphilitic  processes;  but,  owing 
to  the  ever-present  endarteritis  and  consequent  interference  with  the 
nutrition  of  the  syphiloma,  the  inability  to  organize  into  permanent 
connective  tissue  reaches  a  maximum,  and  the  central  part  undei-goes 
fatty  degeneration  and' caseation.  A  gumma  naturally 'tends  to  for- 
mation of  a  cold  abscess ;  if  the  latter  is  superficial,  it  breaks  through 
the  skin  and  thus  gives  rise  to  a  gummatous  ulcer  (Figs.  120, 
122  and  123).     Fig.  121  shows  a  noii-ulcci'ated  abscess. 

For  a  long  time,  tertiary  lesions  were  considered  non-contagious. 
Spirocheta?  in  such  lesions  are  few  in  number  and  less  virulent  than 
in  the  earlier  stages,  but  the  iiiocnlability  of  gummata  has  been 
demonstrated  beyond  doubt. 

Gummata  occur  in  all  tissues  of  the  body.  In  the  skin  and  sub- 
cutaneous tissue  they  first  appear  as  circumscribed  nodules.  After 
a  while,  the  skin  becomes  red  (Fig.  121),  fluctuation  is  felt,  and, 
finally,  a  characteristic  gummatous  ulcer  (see  more  particularly 
Fig.  123)  is  produced.  The  borders  are  hard,  smooth,  not  imder- 
mined,  but  circular  and  sharply  cut,  as  if  punched  out;  the  surface 
is  covered  by  a  tough,  tenacious,  yellowish  deposit,  or  core.  If  the 
latter  be  forcibly  removed,  no  bleeding  occurs  (endarteritis  and 
blocking  of  the  small   arteries). 

In  the  skin  several  gummata  usually  occur  close  together  (Fig. 
121);  these  break  down  in  some  places  and  heal  in  others,  thus 
giving  rise  to  an  irregTilar  or  serpiginous  appearance,  which  is  char- 
acteristic of  tertiary  syphilitic  ulceration  (Figs.  120  and  123). 

Gummata  of  the  skin  or  mucous  membranes  may  extend  to  the 
deejier  tissues,  and  vice  versa.  Diffuse  giimmatous  infiltration  of 
the  skin  and  subcutaneous  tissue  gives  rise  to  multiple  fistulas,  which 
discharge  a   scanty  secretion. 

Gummata  may  cause  extensive  deformity  by  destruction  of  tissue, 
especially  in  the  face  (Fig.  120)-  Tn  these  eases  the  soft  parts  and 
bones  are  generally  aifocted  together,  whichever  may  have  been 
primarily  atfected.  This  leads  to  necrosis  of  the  bone.  One  of  the 
most  frequent  localizations  of  this  gummatous  infiltration,  suppura- 
tion and  necrosis  process,  is  the  nose  and  hard  palate ;  it  is  also  one  of 
the  most  disfigiiring,  and  one  of  the  most  painful  and  disagreeable  for 
the  patient  (dysphagia  and  offensive  smell). 

Primary  gummata  of  the  bones  may  develop  in  the  periosteum, 

ISL 


cortex  or  medulla,  as  circumscribed  growths  or  a  diffuse  infiltration. 
Generally,  all  three  parts  are  affected  with  simultaneous  destruction 
and  proliferation,  causing  an  irregular,  corroded  appearance  of  the 
bone.  Gummatous  osteitis  may  undergo  fibrous  transformation,  or 
may  suppurate,  cause  necrosis  and  lead  to  ulcer  formation  (Fig. 
122).  Necrosis  of  the  cranial  bones  often  leaves  circular  cavities, 
to  which  the  smooth,  glistening  skin  is  firmly  adherent. 

Syphilitic  disease  of  the  tibia  is  the  most  frequently  seen  in  the 
long  bones.  The  weight  of  the  body  may  produce  a  curvature  of  the 
bone.  Abnormal  brittleness  of  the  latter,  possibly  leading  to  spon- 
taneous fracture,  is  not  very  rare. 

Examination  by  X-rays  shows  irregular  shadows  in  the  periosteal  . 
region,  while  the  cortex  and  medulla  cannot  be  distinguished  from 
one  another.    The  whole  bone  is  thickened  and  irregular. 

Patients  often  complain  of  pain,  chiefly  nocturnal,  in  the  bones 
(osteocopic  pains)  before  any  changes  are  visible.  Palpation  of  the 
anterior  surface  of  the  tibia  often  reveals  an  irregular,  uneven  sur- 
face. The  ulna  and  radius  (Fig.  122),  fibula,  sternum  and  clavicle 
may  also  be  the  seat  of  syphilitic  osteitis. 

Articulations  are  also  involved  in  tertiary  syphilis,  either  by 
gummatous  infiltration  of  the  perisynovial  tissue,  or  specific  osteitis 
of  the  articular  ends.    The  knee  is  the  joint  most  frequently  affected. 

Gummata  are  also  seen  in  the  muscles  (gastrocnemii,  sterno- 
cleido-mastoid,  tongue).  Gumma  of  the  tongue  (Fig.  119)  is 
usually  situated  in  the  centre,  and  associated  with  sclerous  glossitis, 
and  may  make  the  organ  assume  a  bifid  shape,  as  shown  in  the  figure. 

The  brain,  the  liver,  the  heart,  the  testicles,  the  lungs,  the  thyroid 
gland,  the  pancreas,  the  adrenals  can  all  be  the  seat  of  gummatous 
degeneration.  Each  localization  has  its  special  symptoms.  Par- 
ticularly interesting  are  the  gTimm.ata  of  glands  having  an  internal 
secretion,  and  their  possible,  but  not  yet  elucidated,  relationship  with 
symptom  complexes  depending  on  alterations  of  those  glands  (pan- 
creas and  diabetes,  adi'enals  and  Addison's  disease). 

In  hollow  viscera,  pharynx,  larynx,  rectum,  the  cicatrization  of 
gummatous  ulcerations  entails  marked  deformity,  on  account  of 
cicatricial  stenosis. 

The  constancy  of  vascular  lesions  in  syphilis  explains  the  fre- 
quency of  post-syphilitic  arterial  degenerations  (see  about  aneurysm, 
page  106,  and  arteriosclerosis,  page  205). 

Congenital  syphilis  may  be  congenital  in  the  strict  sense  of  the 

182 


BockoiilieiiHcr,  Alias. 


Tab.  XCVI. 


-n 


O 


Kcbinan  Company,  New-Yorl;. 


word,  that  is,  exist  at  the  lime  of  liiiili,  or  be  delayed  in  its  appear- 
ance several  years. 

Among  the  characteristic  sigiis  of  early  liereditary  syphilis  are 
bullous  syphilides  of  the  palms  and  soles  {syphilitic  pemphigus)  and 
epiphysitis.  The  latter. is  a  form  of  osteochondritis  affecting  the 
epiphyses  of  the  long  bones,  and  causing  thickening.  It  is  more  com- 
mon in  Iho  aim  and  gives  rise  to  impotency  of  the  limb  (Parrot's 
syphilitic  ])S(.'U(li)-)iai'alysis).  ]<4)ipliysitis  may  inlcrlVro  willi  the 
growth  of  the  limb. 

In  late  hereditary  syphilis  the  l)ones  are  frequently  affected  with 
gummatous  processes  identical  with  those  of  acquired  syphilis.  The 
tibias  are  often  curved  forward  and  outward  owing  to  osteoplastic 
periostitis.  This  condition  is  known  as  "saber  blade  tibia,"  and  is  a 
characteristic  sign  of  late  hereditary  syphilis.  The  skin  over  tlie 
bones  is  often  ulcerated. 

Syphilitic  dactylitis  may  occur  in  both  early  and  late  hereditary 
sy])hilis.  It  causes  thickening  of  the  phalanges,  usually  the  basal 
Olios.  It  is  generally  multiple,  sometimes  bilateral,  and  tends  to  spon- 
taneous resolution  without  suppuration. 

The  bones  in  hereditary  syphilis  are  often  very  brittle.  Other 
signs  of  hereditary  syphilis  are  interstitial  keratitis,  deafness  (due  to 
disease  of  the  internal  ear),  notching  of  the  incisor  teeth  (Hutchin- 
son's teeth).  These  three  signs  have  been  called  the  "Triad  of 
Hutchinson."  Radiating  scars  around  the  mouth  left  bt  former  ulcer- 
ations are  also  characteristic. 

Acquired  syphilis  may  also  occur  in  infants  and  children,  but  it 
then  in  no  wise  differs  in  its  evolution  from  the  acquired  syphilis  of 
full-grown  subjects.  It,  however,  markedly  stunts  the  growth  of 
the  body. 

Diagnosis 

Syphilis  is  so  loidespread  among  all  classes  of  society  that  it  unist 
ahcays  be  borne  in  mind  in  cases  of  doubtful  diagnosis. 

No  cii-cumstantial  evidence,  no  consideration  of  social  standing 
or  of  personal  habits  may  ever  be  made  suflicient  ground  for  an 
a  priori  rejection  of  the  diagnosis  of  syphilis.  Syjihilis  is  ul)ii|nitous 
and  polymorphous  to  the  extreme. 

The  diagnosis  of  syphilis  must  be  made  as  early  as  possible. 
Not  many  years  ago,  the  only  evidence  wo  bad  at  our  disposal  to 
decide  whether  a  chancre  was  syphilitic  or  not  was  purely  clinical. 
The  features  well  shown  in  Fig.  118,  iiarticularly  Iho  cartilaginous, 

183 


elastic  induration  of  the  base,  the  appearance  of  the  regional  adenitis, 
and  finally,  the  secondaries  allowed  of  an  easy  recognition  in  a  great 
majority  of  cases.  Bnt  the  diagTiosis  could  be  made  with  certainty  only 
if  several  signs  were  present;  often,  it  was  necessary  to  ivait  to  ob- 
serve the  evolution,  and  this  is  no  longer  considered  as  desirable,  but, 
on  the  contrarjr,  as  very  detrimental  to  real  therapeutic  success. 
The  discovery  of  the  Spiroclieta  'pallida  has  enabled  us  to  depend  less 
exclusively  on  clinical  evidence  (which,  however,  remains  of  the 
utmost  importance,  but  sometimes  is  deceptive,  owing  to  the  frequent 
existence  of  mixed  infection),  and,  nevertheless,  to  make  an  earlier, 
more  certain  and  more  accurate  diagnosis.  In  every  suspicious  sore, 
wherever  located,  search  must  be  made  for  the  spirochetes,  in  the 
serosity,  either  directly  with  the  dark  ground  illuminator  or  after 
staining.  The  India  ink  stain  is  technically  the  most  rapid  and  the 
.simplest:  the  identification  of  the  spirochetse  may  be  a  little  more 
difficult,  but  with  some  practice  the  method  is  fairly  safe  and  satis- 
factory; it  however  remains  inferior  to  the  dark  field  illuminator, 
which  observes  the  living  features  of  the  organism. 

When  spirochetce  pallidce  are  found,  it  at  once  clears  the  diagnosis, 
and  treatment  must  be  started  without  delay. 

(Compare  the  objective  aspect  of  chancre  (Fig.  118)  and  car- 
cinoma (Figs.  1,  7,  8,  9). 

Secondary  syphilides  of  the  skin  and  mucous  membranes 
may  be  mistaken  for  various  affections,  though,  when  a  number  of 
symptoms  are  present  and  they  are  all  taken  in  consideration  to- 
gether, hesitancy  is  hardly  possible.  Here  also  laboratory  methods 
bring  an  extremely  important  adjunct  to  clinical  investigation, 
namely,  the  complement  fixation,  or  Wassermann  reaction. 

The  latter  is  not  of  much  usefulness  in  the  diagnosis  of  chancres, 
because  it  is  not  present  from  the  beginning,  and  it  sometimes  de- 
velops rather  late  in  the  primary  stage,  but  in  the  secondary  period 
and,  generally  speaking,  while  the  disease  is  active,  it  remains 
positive.  The  diagnostic  value  of  the  test  is  greatly  enhanced  by  the 
fact  that  it  exists  only  in  a  few  other  diseases,  which  cannot  be  mis- 
taken for  syphilis  (scarlet  fever,  noma,  leprosy).  Therefore,  a  posi- 
tive reaction  means  syphilis;  but  a  negative  reaction  has  much  less 
value,  because  it  does  not  mean  necessarily  that  there  are  no 
spirochetae  in  the  body,  but  simply  that  if  any  are  present  they  are 
either  too  few  in  number  to  induce  antibody  formation,  or  encapsu- 
lated so  that  their  toxins  do  not  enter  the  circulation.    Encapsulation 


184 


being  frequent  in  tertiary  lesions,  it  is  readily  understood  why  many 
manifestly  luetic  conditions  are  accoinpanied  by  a  ne«-ative  reaction. 

Negative  Wassermann  tests  acquire  value  only  wiien  a  series  in 
the  same  patient  covering  a  long  period  of  time  (a  year)  gives  uni- 
fprmly  negative  results  (jiiid  ,ill  p()ssii)ilities  of  defective  technique 
have  been  eliminated)  and  tlinc  a:,,  no  active  clinical  manifestations. 
However,  valuable  as  it  is,  the  Wnsseimcnnt  reaction  is  but  one  ele- 
ment of  diagnosis,  and  it  cannot  be  made  the  sole  criterion  of  diag- 
nosis, prognosis  and  treatment.  There  has,  jierhaps,  Ijccn  a  little 
exaggeration  in  this  respect. 

For  the  diagnosis  of  tertiary  lesions  laboratory  methods  do  not 
bring  as  much  help  as  in  the  earlier  stages,  as  spirochetal  are  not  to 
be  found  in  the  discharge  of  gummatous  ulcers,  and  the  Wassermann 
reaction  is  negative  in  a  considerable  proportion  of  cases.  The  luetin 
reaction  (Noguchi)  has  not  yet  been  sufficiently  studied.  Conse- 
quently, the  clinical  diagnosis  still  retains  all  of  its  former  im- 
portance. 

Tuberculosis  and  tumors  are  the  two  great  causes  of  error  in 
the  diagnosis  of  gummata. 

Tuherculons  ulcers  have  an  anemic  ap):)earance.  undermined  edges, 
no  yellow  core  (see  Fig.  130);  tuberculous  pus  is  thin.  In  the 
testicle  gumma  begins  in  the  testicle  itself,  while  tuberculosis  begins 
in  the  epididymis  (see  page  203). 

In  muscles,  in  the  brain,  liver,  spleen  and  other  internal  organs, 
the  symptoms  of  gimima  are  at  first  those  of  tumor,  audit  is  only  by 
the  anamnesis,  the  Wassermann  reaction  and  a  process  of  exclusion 
that  the  real  diagnosis  may  be  reached. 

We  have  already  spoken  of  the  diagnosis  between  gumma  and 
cancer  about  carcinoma  of  the  tongue  (see  Figs.  7,  8  and  9,  and 
page  10;  compare  with  Fig.  119).  and  carcinoma  of  the  lip'  (see 
page  6;  compare  Figs.  3  and  5  with  Fig.  120). 

Diffuse  gummatous  infiltration  of  the  skin  with  fungoid  prolifera- 
tion may  suggest  sarcoma  (cf.  Figs.  24  and  26),  but  differs  in  the 
absence  of  any  tendency  to  bleeding,  in  the  presence  of  circular  scars 
and  brown  pigmentation  of  the  surrounding  skin,  and  the  existence 
of  other  signs  of  syphilis. 

Central  gumma  of  bone  may  resemble  central  sarcoma  or  bone 
cyst,  and  may  give  the  same  appearance  on  X-ray  examination,  but 
gummatous  changes  in  bone  are  characterized  bv  inqilication  of  the 
periosteum.      In    doubtful    cases,    a    test    course    of    antisyphilitic- 

185 


(Salvarsan)  treatment  may  be  given,  but  too  much  time  must  not  be 
wasted  (see  page  11). 

A  gummatous  ulceration  such  as  that  sliown  in  Fig.  123  somewhat 
resembles  objectively  a  furuncle  (see  Fig.  87),  but  the  evolution  is 
so  different  that  no  confusion  is  possible. 

Gummata  must  also  be  distingTiished  from  the  lesions  of 
sporotrichosis,  an  infectious  granuloma,  chiefly  of  the  skin  and  sub- 
cutaneous tissue,  due  to  the  sporotrichum  fungus,  first  described  by 
Schenck,  later  by  Hektoen  and  Perkins,  and  well  studied  by  French 
writers,  foremost  among  whom  de  Beiirmann  and  Gougerot.  The 
nodular  formations  and  indolent  abscesses  of  sporotrichosis,  which 
particularly  affect  the  arm  and  forearm,  can  be  clinically  suspected, 
but  truly  identified  only  by  culture  of  the  fungus ;  these  are  charac- 
teristic, with  their  radiating  fringe  of  mycelia  extending  deep  into  the 
medium  as  a  white  mass ;  microscopical  examination  shows  the  typi- 
cal ovoid  spores.  Histologically  the  lesions  of  sporotrichosis  cannot 
be  differentiated  from  those  of  tuberculosis,  and  it  is  very  likely  that, 
in  former  times,  many  cases  have  been  diagnosed  and  treated  either 
as  syphilis  or  tuberculosis. 

In  congenital  syphilis  the  lesions  are  generally  typical  and  the 
Wassermann  is  always  strongly  positive. 

In  parasyphilitic  affections,  the  frequent  occurrence  of  a 
sti'ongly  positive  Wassermann  indicates  that  there  is  still  an  active 
syphilitic  process,  and  gives  a  hopeful  therapeutic  indication.  In 
many  eases  of  parasyphilitic  conditions  of  the  nei'vous  system,  the 
blood  Wassermann  may  be  negative,  wliile  the  test  made  with  the 
cerebro-spinal  fluid  is  unmistakably  positive.  Examination  of  the 
same  cerebro-sijinal  fluid  for  lymphocytosis  and  albumin  contents 
also  gives  positive  results. 

T^reatment 

The  treatment  of  syphilis  must  he  begun  as  soon  as  the  diagnosis 
is  made. 

It  must  he  kept  up  until  all  clinical  manifestations  have  disap- 
peared, and  the  Wasserman^t  reaction  has  hecome  permanently 
negative. 

If,  for  a  year,  the  reaction  remains  steadily  negative  in  a  patient 
who,  meanwhile,  has  not  received  any  treatment,  the  presumption 
of  a  cure  is  justified ;  but,  ujd  to  now,  we  have  no  decisive  proof  of  a 
radical  cure  of  syiDhilis,  except  when  genuine  reinfection  occurs,  and 


186 


Hockeiiheinier,  Atlas. 


Tab.  XCVII. 


Rebman  Company,  New-Vork. 


this  seems  to  beoonie  innfli  more  frequent  with  the  newer  methods  of 
treatment  (Fordycc). 

All  direct  syphilUic  processes  are  influenced  by  antisyphilitio 
treatment.  Parasyphilitio  con'ditions  are  not  so  favorably,  and  it  has 
long  been  claimed  that  they  were  not  at  all,  influenced;  but  this  is  no 
longer  strictly  true  for  some  of  them,  though  remaining  the  general 
rule. 

The  treatment  of  syphilis,  formerly  restricted  to  mercury  and 
iodine  derivatives,  chiefly  iodides,  and  already  satisfactory,  has  been 
considerably  strengthened  in  the  i^ast  three  years  by  the  discovery  of 
salvarsan,  and  quite  recently,  by  that  of  neosalvarsan.  Whatever 
may  be  argued  about  the  curative  value  of  these  drugs  in  the  general 
treatment  of  syphilis  (a  question  which  time  alone  can  answer),  it 
cannot  be  gainsaid  that  they  have  very  remarkable  healing  prop- 
erties on  all  syphilitic  lesions,  primary,  secondary  and  tertiary,  even 
on  those  types  that  formerly  proved  refractory  to  mercury  and 
iodides. 

Neosalvarsan  is  somewliat  slower  in  its  action  than  salvarsan; 
but  it  is  also  less  toxic,^  much  easier  to  administer,  and  can  be  used  in 
much  higher  doses,  at  shoi't  iutervals— an  invaluable  advantage  in  the 
attempted  abortive  treatment  of  early  eases. 

If  the  diagTiosis  of  chancre  is  made  early  (within  two  weeks  of 
the  onset),  a  series  of  four  or  five  intravenous  injections  of  neosal- 
varsan every  other  day,  so  that  the  total  dose  is  at  least  4.5  grams 
(corresponding  to  .3  grams  of  salvarsan),  or  more  in  strong  indi- 
viduals, is  well  tolerated,  and  may  abort  the  disease;  that  is,  the 
Wassermann  reaction  never  becomes  positive,  and  no  secondaries 
develop.  Of  course,  the  Wassermann  must  be  taken  at  frequent  in- 
tervals and  the  treatment  resumed  at  the  slightest  indication  of  the 
reaction  tending  to  become  positive  again.  It  is  even  wiser  syste- 
matically to  start  a  course  of  mercurial  treatment  (inunctions"  and 
injections)  shortly  after  the  first  series  of  neosalvarsan  injections, 
and  three  months  later,  to  give  two  more  intravenous  injections. 

When  the  diagnosis  is  made  later,  when  the  Wassermann  is 
already  positive,  and  a  fortiori  when  secondaries  have  developed,  an 
abortive  treatment  is  no  longer  possible;  but  the  treatment  must  re- 
main intensive  and  prolonged.  Insufficient  treatment  is  the  source  of 
all  neuro-recurrences.  This  does  not  necessarily  mean  that  high  doses 
must  be  given;  smaller  doses  frequently  repeated,  and  mercurial 
treatment  between  the  salvarsan  courses,  seem  to  be  better  adapted  to 

'Thou^rli,  piobahly,  Hliglitly  more  veurotropic. 

187 


the  nature  of  syiDliilis,  a  chronic  intermittently  relapsing  disease, 
calling  for  a  chronic  intermittent  treatment.  The  Wassermann  reac- 
tion is  the  best  guide  for  the  treatment;  latent  cases  with  a  positive 
Wassermann  must  be  deemed  active*  cases,  in  silent  relapse,  and 
treated  accordingly. 

Salvarsan,  and  also  mercurial  treatment,  have  a  decided  influ- 
ence on  the  Wasserm.ann  reaction.  However,  this  action  becomes  less 
mai'ked  with  the  age  of  the  disease,  and  a  positive  Wassermann  in  an 
old  case  is  generally  very  hard,  if  not  impossible,  to  change  into  a 
negative. 

In  tertiary  lesions,  salvarsan  treatment  works  wonders  in  most 
cases.  Several  intravenous  infusions  of  0.6  gm.  (on  the  correspond- 
ing amount  of  neosalvarsan)  will  make  a  gummatous  infiltration  melt 
very  quickly  without  leaving  any  traces,  or  will  cause  an  ulcer  to  heal 
in  much  less  time  than  was  formerly  needed  with  mercury  and  iodides. 
Of  course,  if  further  treatment  is  desired  for  general  vascular  lesions, 
after  the  gumma  has  healed,  iodides  must  be  resorted  to.  When  a  lip 
or  the  nose  have  been  destroyed  by  a  gmmma,  plastic  repair  of  the 
defect  may  be  required.  But  it  henceforth  will  be  very  exceptional 
that  a  syphilitic  lesion  will  require  more  than  anti syphilitic  treatment 
(for  instance,  scraping  in  ulcers,  extraction  of  sequestra  in  osteitis). 
We  now  can  make  a  diagnosis  early  enough,  and  have  a  treatment 
powerful  enough,  to  be  able  to  prevent  any  syphilitic  lesion  from 
causing  irretrievable  destruction  of  tissue. 

In  congenital  syphilis,  salvarsan  treatment  is  also  efficient,  but 
the  Wassermann  reaction  is  never  changed. 

In  parasyphilitic  diseases  of  the  nervous  system,  salvarsan  treat- 
ment sometimes  seems  to  give  favorable  symptomatic  results.  Its 
real  value  is  not  yet  fully  established.  It  is  contraindieated  in  ad- 
vanced lesions  of  the  nervous  system  and  in  marked  cardiovascular 
disease. 


188 


Bockeiilieimer,  Atlas. 


Tab.  XCVIII. 


Fig.  124.     Lymphomata  colli  tuberculosa. 


Rclinian  Conipnny    New- York. 


TUBERCULOSIS 

Figs.  124  to  131,  iiirhisive,  show  a  number  of  conditions  all 
caused  by  tlie  tuberculosis  bacillus.  They  all  belong  to  the  types 
termed  "surgical"  tuberculosis;  those  cases  are  nowadays  generally 
attributed  to  the  bovine  bacillus,  while  the  "medical"  forms,  tubercu- 
losis of  the  lungs,  internal  viscera  and  acute  miliary  tuberculosis,  are 
due  to  the  humane  bacillus. 

"Whether  tuberculosis  is  chiefly  an  iuliahdion  or  an  i)tfjesfion 
disease  is  still  a  nuich  debated  question.  From  a  practical  standpoint 
it  matters  little  which  mode  is  the  more  frequent:  both  are  possiljle, 
and  both  must  be  guarded  against. 

"Surgical"  tubercidosis  lesions,  such  as  those  here  figured,  are 
seldom  primary;  almost  always,  if  not  always,  they  are  secondary 
to  a  primary  focus  situated  elsewhere  in  the  body  (most  often  lungs 
and  bronchial  h'mph  glands).  The  propagation  is  generally  acbnitted 
to  take  place  by  the  blood;  but  the  lympJiogenous  origin  of  many  a 
case  is  now  established. 

The  tuberculosis  bacillus  may  settle  in  all  tissues  of  the  body:  it, 
however,  has  a  preference  for  some  of  them.  The  muscular  tissue  is 
the  least  frequently  affected.  Among  surgical  cases,  the  lymph 
glands  (Fig.  124),  the  bones  and  articulations  (Figs  125  to 
128,  inclusive,  130  and  131 )  are  the  most  frequent  sites.  All  glandu- 
lar organs  are  often  involved.  Fig.  129  shows  a  very  common  con- 
dition, tuberculosis  of  the  testicle. 

When  the  bacillus  invades  an  organ,  it  sets  up  an  inflammatory 
reaction  in  the  surrounding  tissues.  After  the  first  stage  of  leucocytic 
infiltration,  common  to  all  infections  (see  page  117),  the  reaction  of 
the  tissues  to  the  tuberculosis  bacillus  assumes  a  special  type,  which 
leads  to  the  formation  of  a  tubercle.  In  the  latter,  there  always  are 
a  large  number  of  round  cells,  and  in  fresh  tubercles  ejjithelioid  cells; 
in  older  tubercles,  giant  cells,  which  ai'e  agglomerations  of  leucocytes 
engaged  in  the  destruction  of  bacilli. 

The  tubercle  exhibits  a  double  tendency  in  its  evolution.  Owing 
to  the  absence  of  blood-vessels  in  its  centre,  the  latter  undergoes 
caseation ;  but,  at  the  same  time,  thei-e  is,  at  the  periphery,  a  natural 
tendency  to  limit  and  surround  the  focus  by  hypei;production  of 
fibrous  tissue.  Central  caseation  and  purulent  disintegration,  on 
the  one  hand,  and  perijiheral  sclerosis,  on  the  other  hand,  always 

189 


progress  simultaneously,  but  not  necessarily  equally.  According  to 
whether  one  or  the  other  process  is  more  marked,  or  both  are  equal, 
the  tubercle  becomes  caseous,  or  fihro-caseous,  or  fibrous,  and  the  evo- 
lution is  toward  aggravation,  a  stationary  or  slowly  progressive  con- 
dition, or  spontaneous  recovery. 

Eecovery  may  occur  spontaneously  by  fibrous  encapsulation  of 
the  focus,  which  then  becomes  simply  quiescent  or  undergoes  calci- 
fication. Judging  from  the  results  of  autopsies  of  old  people,  about 
70%  of  all  subjects  have,  at  one  time  or  another,  harbored  in  their 
body  tuberculous  foci  which  have  spontaneously  healed.  But  a  simply 
quiescent  focus  is  always  a  menace  to  health.  Under  the  influence 
of  trauma  or  of  decreased  resistance  of  the  body,  it  may  become  active 
again,  give  rise  to  new  lesions  or  even  to  generalized  miliary  tuber- 
culosis. 

Recovery  may,  and  in  fact  does  often,  take  place  after  caseation, 
and  formation  of  a  cold  abscess:  such  abscesses  generally  open  out- 
side, and  become  fistulous.  Tuberculous  fistula  are  surrounded  by 
pale,  anemic-looking,  vitreous  granulations.  They  run  an  irregular 
course  and  sometimes  open  at  distant  points  of  the  skin  (especially 
in  bone  tuberculosis) ;  the  walls  of  the  fistula  are  soft  and  bleed 
easily.  The  pus  is  thin  and  mixed  with  fibrin,  caseous  masses  and 
shreds  of  tissue.  The  tuberculous  ulcer  is  characterized  by  thin,  soft, 
ragged,  vmdermined  borders,  and  a  base  covered  with  yellow,  caseous 
masses,  or  pale-red  or  gray  granulations.  Tuberculous  granulations 
may  destroy  all  the  surrounding  tissues  (bones,  cartilage  and  muscles) . 
In  these  cases,  the  extension  is  almost  indefinite,  as  there  is  but  little 
fibrous  tissue  formation.  Besides,  external  fistulization  of  a  tuber- 
culous lesion  almost  unavoidably  entails  the  risk  of  secondary  pyo- 
genic infection,  a  decidedly  unfavorable  element.  The  pus  of  tubercu- 
lous fistulfe  is  not  very  virulent,  and  the  danger  of  tuberculous  con- 
tamination by  open  foci  of  "surgical"  tuberculosis  is  negligible,  if 
not  absolutely  nil. 

Diagnosis  and  prognosis 

The  diagnosis  in  case  of  open  lesions  is  often  not  difficult.  It  has 
to  be  examined  separately  for  each  special  localization  of  the  disease 
(see  below). 

A  doubtful  diagnosis  of  tuberculosis  may  be  confirmed  by  intra- 
peritoneal inocidation  to  the  guinea-pig,  microscopical  examination, 
or  a  tuberculin  test,  subcutaneous  {von  Pirguet),  intradermic  (Man- 
toux)  or  percutaneous  (Moro).  The  inoculation  is  the  most  accurate 
and  reliable  method;  unfortunately,  it  entails  too  long  a  delay. 

190 


It  is  futile  to  look  for  the  tubercle  bacillus  in  smears  of  tubercu- 
lous pus  of  ulcerated  lesions;  it  is  never  found.  If  no  associated  pyo- 
genic infection  is  present,  the  pus  seems  to  contain  only  pus  cells  and 
no  micro-organisms  at  all.  Such  a  pus  uritJiout  microbes  is  always 
very  suggestive  of  tuberculosis. 

The  prognosis  depends  on  the  extension  of  the  disease,  the  power 
of  resistance  of  the  ])ationt,  and  the  tendency  to  fibrous  tissue  foi*- 
mation.  The  extension  of  the  disease  is  directly  influenced  by  an 
early  diagnosis  and  appropriate  treatment. 


It  must  be  prophiilactic,  general  and  local. 

We  cannot  discuss  liere  at  full  length  the  prophylaxis  and  general 
treatment  of  tuberculosis.  Suffice  it  to  say  that  in  surgical  conditions 
the  latter  is  always  indicated  and  that,  particularly  in  children,  sun- 
shine (heliotherapy)  and  seaside  treatment  will  work  wonders,  and, 
with  conservative  measures,  often  bring  about  a  cure;  while  in  full- 
grown  subjects,  operative  measures  are  more  frequently  called  for. 

Tuberculin  treatment  (TR  or  BE)  has  been  much  discussed  in 
recent  years.  If  applied  in  such  a  way  as  not  to  cause  general  febrile 
reactions,  it  has  a  certain  usefulness,  chiefly  against  toxic  symptoms, 
and  is  not  harmful.  Consequently,  as  an  adjuvant  to  other  treatment, 
it  is  welcome;  but  it  cannot  alone  take  the  place  of  other  treat)ne)it, 
except,  perhaps,  in  very  early  cases;  even  then,  the  evidence  at  hand 
is  still  to  meager  to  allow  definite  conclusions. 

Surgery  does  not  cure  tuberculosis,  but  it  considerably  helps  the 
natural  defense  of  the  body,  and  may  turn  the  tide  of  battle  in  favor 
of  the  latter,  while  before  operation  the  tuberculous  process  had  the 
better  of  it.  A  striking  example  is  afforded  by  reno-vesical  tubercu- 
losis. As  long  as  the  tubercidous  kidney  remains  in  place,  all  treat- 
ments are  unavailing  to  cure  the  bladder  ulcerations;  as  soon  as  the 
kidney  is  removed,  those  same  ulcerations  heal  up,  often  without 
special  treatment.  It  must  be  remembered  that  surgical  eases  of 
tuberculosis  are  scco)idary  to  a  ])rimary  focus,  which  generally  cannot 
be  reached;  that,  therefore,  our  operations  for  tuberculous  conditions 
^lacnnevcr  ihilni  to  hi'  nulhiil.  luit  arc  only  jiiirlhtl. 

Each  typo  of  surgical  tuberculosis  gives  rise  to  special  therapeutic 
indications,  to  be  considered  later  on.  We  shall  here,  however,  to 
avoid  repetitions,  set  forth  briefly  the  gouernl  methods  of  treatment. 

If  the  focus  is  ((ppdrciilh/  well  luc-ilix.cil  (tuberculosis  of  the  skin, 
of  the  kidney,  of  llic  lyiniih  ghuuls,  for  instance),  extirpation  is  the 
method  of  choice.     We  know  that  there  is  no  really  localized  tubereu- 

1!)1 


losis;  but,  in  many  cases,  even  a  very  incomplete  removal  of  the 
diseased  tissue  will  considerably  help ;  as  the  natural  defensive  power 
of  the  body,  ivMchj  after  all,  is  the  one  curative  agent  i»  tubercu- 
losis, will  be  able  to  do  the  rest.  Tliis  explains  wliy  scraping  of 
tuberculous  lesions  (some  forms  of  lupus,  and  chiefly  open  fistulous 
foci)  aften  does  so  much  good. 

Hyperemia  in  tuberculous  lesions  is  not  as  useful  as  in  acute  jTyo- 
genic  infections :  active  hyperemia  is  absolutely  contraindicated ; 
passive  hyperemia  must  be  very  carefully  handled  and  its  results  are 
uncertain. 

Whenever  a  focus  undergoes  caseation  and  causes  an  abscess,  our 
aim  at  first  must  always  be  to  bring  about  a  cure  without  external 
opening,  because  of  the  danger  of  secondary  infection.  Therefore, 
primary  incision  of  a  cold  abscess  is  not  advisable :  if  a  tuberculous 
pus  collection  threatens  to  ulcerate  the  skin  and  become  fistulous,  it 
is  better  to  ward  off  this  eventuality  by  tapping  (not  directly  over 
the  swelling,  which  would  immediately  lead  precisely  to  what  we  are 
seeking  to  avoid,  namely,  fistulization,  but  very  obliquely,  so  as  to 
make  a  long  subeutaneoxTS  track,  which  closes  readily)  and  injecting 
within  the  abscess  cavity  some  fluid  capable  of  happily  influencing 
the  evolution  of  its  walls;  camphor  naphthol,  iodoform  dissolved  in 
ether  (5%)  or  suspended  in  glycerin  (10%).  Iodoform  has  long  been 
credited  with  a  special  influence  on  tuberculous  fungosities;  it  cer- 
tainly works  well,  better  than  any  other  substance.  These  tappings 
may  be  repeated ;  they  are  often  sufficient,  when  combined  with  gen- 
eral treatment,  to  bring  about  a  cure  without  open  operation;  but 
if,  despite  the  injections,  a  fistula  develops,  exposure  of  the  focus  and 
scraping  is  generally  indicated. 

For  the  treatment  of  tuberculous  fistute,  either  developed  spon- 
taneously, or  persisting  after  an  operation.  Beck  has  strongly  urged 
the  employment  of  vaselin-bismutli  (33%)  paste  as  a  filUng  mass. 
When  no  foreign  bodies  are  behind  the  fistula  (sequestra,  for  in- 
stance), Beck's  method  is  successful  in  a  gTeat  number  of  cases  and 
undoubtedly  is  very  valuable.  The  danger  of  bismuth  poisoning 
exists,  but  is  very  small,  and  is  nil  when  dealing  with  not  too  large 
a  cavity.  The  method  is  applicable,  no  matter  what  organ  (bone, 
lymph  and  gland,  etc.)  is  the  origin  of  the  fistula. 

Fig.  124  represents  a  case  of  tuberculosis  of  the  submaxillary 

and  cervical  glands,  in  a  man  who  since  youth  had  sutfered  from 
eczema  of  the  face  and  inflammation  of  the  eyelids. 

While  tuberculous  lymphangitis  is  rare  and  occurs  only,  in  the 

193 


form  of  nodular  cords,  in  connection  with  tuberculosis  of  the  skin 
or  lymph  M'Uuids,  tuberculous  adenitis  is  extremely  frequent  and 
surgically  important. 

All  lymph  glands  of  tlio  liody  may  be  affected,  but  not  with  equal 
frequency.  Tuberculosis  ol'  the  visceral  glands  chiefly  concerns  the 
intci-iiist.  Tuberculous 'ndeiiitis  is  not  common  in  the  axillary  and 
inguinal  glands,  but  it  is  very  frequent  in  the  glands  of  the  neck  in 
children.  Tul)erculous  adenitis  of  the  neck  is  one  of  the  chief  elements 
of  what  was  formerly  called  "scrofula" ;  that  is,  a  seemingly  not  very 
virulent  form  of  tuberculosis,  in  which  repeated  attacks,  as  evidenced 
by  chronic  blepharitis,  eczema,  tori)id  ulcers,  otitic  dischai'ge,  have 
apparently  induced  some  general  immunity.  The  portal  of  entry  is 
generally  found  in  the  mouth  or  pharynx.  Acute  infectious  diseases 
with  bucco-pharyugeal  lesions  (scarlet  fever,  measles,  etc.)  are  fre- 
quent predisposing  causes. 

In  the  glands,  the  bacilli  first  induce  the  formation  of  miliary 
tubercles.  Several  of  the  latter  become  confluent  and  form  larger 
nodules.  Later  the  process  extends  to  the  iDeriglandular  tissue  and 
skin.  Then  the  node  is  no  longer  covered  by  intact  skin  under  which 
it  is  freely  movable,  but  l)ecomes  adherent.  The  skin  finally  ulcerates 
and  a  cold  abscess  discharges  typical  thin  greenish  pus,  often  in  places 
remote  from  the  primary  node. 

The  differential  diagnosis  of  cervical  adenitis  has  already  been 
considered  on  -page  31,  about  Fig.  24.  Some  cases  are  typical  and 
the  diagnosis  is  e.asy:  this  is  particularly  true  of  those  cases  in 
children  which  are  accompanied  by  the  scrofula  mask  (thick,  prom- 
inent upper  lip,  blepharitis,  skin  erui:)tions,  etc.),  or  in  those  cases 
in  which  there  is  a  cluiracteristic  tuberculous  fistula.  Early  in  the 
evolution,  when  there  are  only  round,  movable,  circumscribed  lumps, 
the  diagnosis  is  much  moj-e  diihcult.  Excision  of  one,  microscopical 
examination  and  a  tuberculin  test  may  be  resorted  to. 

The  treatment  must  include  thai  of  the  cause,  and  be  general  and 
local  (see  above.  General  treatment  of  tuberculosis).  Circumscribed 
lymph  gland  abscesses  may  be  tapped  with  a  fine  needle,  and  the 
cavity  injected  with  a  10%  emulsion  of  iodoform  in  glycerin.  Large 
ulcerated  abscesses  may  be  scraped  and  packed  with  iodoform  gauze. 
Fistulas,  especially  when  persistent,  are  successfully  treated  by  injec- 
tion with  Beck's  bismuth  vaselin  paste. 

Good  resiilts  have  been  reported  by  several  writers  from  the  use 
of  X-rays.  But  the  general  tendency  nowadays  is  toward  stirejical 
ablatio)!  when  the  lymi)h  glands  have  not  yet  reached  the  caseation 
and  suppuration  stage,  and  when  general  treatment  alone  is  insuffi- 

193 


eient.  Tuberculous  IjTxipli-giaiids  of  the  neck  are  usually  removed 
by  a  free  longitudiual  incision  along  the  anterior  (or,  less  often,  the 
posterior)  border  of  the  sterno-cleido-mastoid  muscle.  These  glands 
are  always  in  close  connection  with  the  big  vessels  and  nerves  of  the 
neck,  and  not  unfrequently  they  form  a  continuous  chain  from  the 
base  of  the  skull  down  to  the  supraclavicular  fossa. 

Transverse  incisions  {Koclier,  Doivd)  are  preferred  by  many,  be- 
cause they  give  a  much  less  visible  scar,  almost  completely  hidden  in 
the  normal  folds  of  the  skin. 

Gentleness  of  manipulation  and  avoidance  of  undue  squeezing 
of  the  mass  are  required  in  extirpation  of  tuberculous  glands,  so  as 
not  to  send  any  tuberculous  matter  in  the  general  circulation.  In 
removing  glands  with  suppuration  in  their  interior,  care  must  be 
taken  not  to  break  into  them  and  thus  infect  the  wound. 

Figs.  125  to  128,  inclusive,  show  different  types  of  joint  tubercu- 
losis; Figs.  130  and  131  two  cases  of  hone  tuberculosis. 

Joint  and  bone  tuberculosis  (which  must  be  considered  together, 
on  account  of  their  close  relations)  are  surgically  the  two  most  im- 
portant forms  of  tuberculosis. 

Tuberculosis  invades  bones  by  way  of  the  blood.  It  may  invade 
articulations  in  the  same  manner,  but  this  primary  hematogenous 
mode  is  comparatively  rare,  and  tuberculosis  of  joints  is  ordinarily 
secondary  to  a  juxta-epiphyseal  focus  of  bone  tuberculosis  which  has 
extended  to  the  articular  cavity.  The  bones  are  generally  affected  in 
certain  places  according  to  the  distribution  of  their  blood-vessels. 
The  nutrient  artery  of  the  long  bones  terminates  in  the  epiphyses; 
this  explains  the  frequency  of  tuberculous  deposits  in  these  same 
epiphyses,  whence  the  line  of  least  resistance  for  propagation  nat- 
urally leads  through  the  cancellous  tissue  to  the  joint.  In  short  bones 
the  nutrient  artery  ends  soon  after  its  entrance  in  the  middle  of  the 
bone :  hence  the  localization  of  tuberculosis  to  the  middle. 

Among  the  epiphyses  most  frequently  attacked  are  those  of  the 
tibia  and  femur :  hence  the  predominance  of  tuberculosis  in  the  hip, 
knee  and  ankle  joints.    Next  come  the  wrist  and  elbow. 

The  evolution  of  the  tubercle  bacillus  in  bones  is  the  same  as  in 
any  other  tissue  of  the  body.  The  central  necrosis  leads  to  the  for- 
mation of  a  sequestrum.  Small  sequestra  often  give  rise  to  large 
cold  abscesses,  which  become  visible  under  the  skin  (Fig.  125),  often 
at  some  distance.  In  tuberculous  bone  disease  there  is  little  tendency 
to  the  formation  of  new  bone  or  to  peripheral  sclerosis,  therefore, 
little  tendency  to  limitation  or  spontaneous  recovery. 

194 


In  some  rare  cases  tlie  focus  of  disease  may  become  encapsulated 
in  the  bone,  but  is  always  liable  to  recrudescence,  especially  after  an 
injury.  ^More  commonly  the  se(iuestrum  is  discharged  piecemeal 
tlirough  a  listula,  thus  differing  from  the  large  sequestrum  of  pyo- 
genic osteomyelitis.  Multiple  foci  of  disease  often  occur  in  one  or 
more  bones.  When  the  bone  is  exposed  by  incision,  irregular,  cor- 
roded, caseous  fragments  are  seen,  together  with  pus.  When  the 
disease  occurs  in  the  epiphyses  of  the  long  bones  it  may  break  into 
the  joint;  this,  as  already  stated,  is  the  common  causative  mechanism 
of  joint  tuberculosis. 

In  the  ribs,  the  lesions  are  usually  confined  to  the  periosteum  and 
to  the  formation  of  a  large  subperiosteal  abscess.  In  the  phalanges 
tuberculosis  gives  rise  to  a  special  type  of  osteitis  {spina  rentosa, 
Fig.  131),  to  be  spoken  of  later. 

In  joints  not  only  the  articular  ends  are  involved,  but  also  the 
synovial  membrane  and  periarticular  soft  parts.  Here  the  anatomical 
evolution  is  not  as  one-sided  as  in  pure  bone  tuberculosis;  central 
necrosis  and  peripheral  sclerosis  are  better  balanced,  and  instead 
of  the  merely  destructive  type  of  lesions  found  in  bones,  we  find 
mixed  types  due  to  the  predominance  of  one  or  the  other  process. 

First,  in  the  rare  types  of  primary  hematogenous  infection  of  the 
synovial  membrane,  we  find  granulation  tissue  and  effusion  in  the 
joint.  In  the  mildest  forms  the  effusion  may  be  only  serous  (articu- 
lar hydrops),  but  more  commonly  it  is  sero-fibrinous.  The  fibrin 
forms  villous  deposits  on  the  synovial  membrane  and  cartilage,  and 
so-called  "rice  bodies,"  which  are  lumps  of  loose  fibrin  in  the  joint, 
rolled  by  the  motion  of  the  latter. 

A  second  form  is  known  as  fungoid  arthritis,  owing  to  the  forma- 
tion of  fungoid  or  spong>^  granulation  tissue,  which  gives  rise  to 
globular  swelling  of  the  joint.  In  these  cases  the  whole  joint  is  filled 
with  gi-ayish-red  or  yellowish-white  granulations,  and  there  is  only 
slight  exudation.  The  fungous  granulations  tend  toward  caseous 
degeneration,  and  after  a  time  to  suppuration.  This  form  does  not 
remain  limited  to  the  joint,  but  soon  extends  to  the  ligaments  and 
periarticular  structures,  and  eventually  to  the  subcutaneous  tissue 
and  skin  (Figs.  125  and  126). 

A  third  form  is  fibrous  arthritis  (Figs.  127  and  128).  in  which 
there  is  formation  of  hard  fibrous  tissue  in  the  joint.  A  type  of 
this  is  the  caries  sicca  of  Volkmann,  which  is  common  in  the  shoulder 
and  hip  joints,  and  is  characterized  by  a  great  tendency  toward 
atrophy  of  the  articular  end  of  the  bone,  giving  rise  to  dislocations 

195 


and  to  muscular  wasting.  In  distinction  to  the  above  atrophic  form, 
there  is  another,  and  more  frequent,  type  of  fibrous  arthritis,  which 
causes  globular  swelling  of  the  joint  owing  to  the  abundant  formation 
of  fibrous  tissue.  This  is  especially  common  in  the  knee  joint  and 
may  be  mistaken  for  bone  tumor.  It  is  known  as  "white  swelling" 
or  tumor  albus,  on  account  of  the  white  anemic  appearance  caused  by 
pressure  of  the  fibrous  tissue  on  the  skin  (Fig.  128). 

A  fourth,  and  much  less  common,  form  of  tuberculous  joint  disease 
is  purulent  arthritis.  This  is  often  due  to  mixed  infection  of  one 
of  the  above-mentioned  forms  by  staphylococci — for  example,  through 
a  fistula  in  the  skin.  However,  2:)urulent  arthritis  sometimes  occurs 
seemingly  primarily,  especially  in  children  (Fig.  126). 

In  all  these  forms  of  tuberculous  arthritis  the  cartilage  is  much 
damaged  by  the  fibrinous  exudation.  In  fibrinous  hydrops  and  caries 
sicca,  the  corrosive  action  is  generally  limited  to  the  cartilage;  but 
in  fungoid  and  purulent  arthritis  the  whole  epiphysis  may  be  de- 
stroyed, and  the  infection  may  spread  to  the  diaphysis. 

Tuberculous  arthritis  generally  begins  with  pain,  which  is  often 
remote  from  the  affected  joint;  e.g.  in  disease  of  the  Mp  joint  pain 
is  referred  to  the  inner  side  of  the  knee.  This  is  followed  by  slight 
rises  of  temperature  and  pain  in  the  region  of  the  affected  joint. 
Motion  of  the  joint  is  avoided,  the  whole  region  becomes  swollen,  and 
characteristic  positions  are  taken  by  the  different  joints.  Eacli 
assumes  the  position  in  which  its  capsule  reaches  its  greatest  capacity 
(flexion  for  the  knee  and  elbow,  abduction  and  flexion  for  the  hip, 
external  rotation  for  the  shoulder),  and  is  immobilized  in  that  posi- 
tion at  first  by  reflex  contracture,  later  on  by  fibrosis  retraction 
of  the  periarticular  muscles.  The  greater  the  destruction  of  the 
articular  tissues,  the  more  abnormal  the  positions  of  the  affected 
limb. 

There  are  also  some  local  signs.  In  hydrops  there  is  fluctuation. 
In  fungoid  arthritis  the  whole  joint  is  filled  with  soft,  spongy  tissue, 
causing  balloon-like  swelling  of  the  joint;  this  spongy  tissue  extends 
to  the  periarticular  tissue  and  reaches  the  skin,  which  becomes  red- 
dish-blue, and  later  on  breaks  down  into  tuberculous  ulcers  and 
fistulas  (Fig.  125).  Besides  this,  multiple  abscesses  often  develop  at 
some  distance  from  the  joint  (see  in  Fig.  125  the  scar  in  the  middle 
of  the  thigh). 

Recovery  but  seldom  takes  place  with  restitutio  ad  integrum  of 
the  joint  function.  Usually,  in  those  cases  that  recover,  there  is 
ankylosis,  either  fibrous  (Fig.  125)  or  even  bony  (Fig.  127).    Anky- 

196 


losis  must  be  regarded  as  a  favorable  outcome,  and  as  a  process  to  be 
promoted,  not  liinder('<l.  ^Vllen  there  is  no  tendency  to  fil)rosis,  the 
disease  keeps  on  i>roo-re.ssing  until  general  exhaustion,  miliary  tuber- 
culosis, or  amyloid  degeneration  kills  the  patient. 

The  prognosis  is  more  favorable  in  young  individuals  than  in  old 
people. 

The  diagiiosis  of  either  bone  or  .ioint  tuberculosis  is  generally 
easy  when  there  is  a  fistula  discharging  characteristic  thin  tubercu- 
lous pus  mixed  with  caseous  debris  and  fragments  of  sequestrum,  or 
when  there  is  evidence  of  tuberculosis  in  the  lungs  or  other  organs. 
The  differential  characters  of  chronic  osteomyelitis  and  syphilitic 
osteitis  have  already  been  set  forth  (see  page  15'2).  Caries  sicca 
is  characterized  by  the  marked  atrophy  of  the  joint,  the  abnormal 
positions,  the  muscular  wasting  and  complete  loss  of  function.  White 
sicelling  is  recognized  by  the  extensive  tumor-like  swelling  covered 
by  white  skin  (Fig.  128)  and  does  not  much  resemble  bone  tumors 
(see  Fig.  32). 

Tuberculous  hydrops  may  be  mistaken  for  traumatic  effusion, 
gonorrheal  or  syphilitic  arthritis,  hydarthrosis.  The  diagnosis  de- 
pends on  the  history  of  the  case  and  thorough  examination  of  the 
whole  body.  In  doubtful  cases  the  joint  may  be  tapped,  or  inocula- 
tion to  the  guinea  pig  may  be  resorted  to. 

Acute  forms  of  fungoid  tuberculous  arthritis  can  hardly  be  dis- 
tinguished clinically  from  pyogenic  affections  of  the  joint. 

In  cases  whei-e  complete  healing  of  the  joint  has  taken  place,  with 
bony  ankylosis,  it  is  sometimes  impossible  to  distin,guish  tuberculous 
cases  from  joint  disease  secondary  to  pyogenic  osteomyelitis  of  the 
diaphysis.  In  old  people  healed  tuberculous  joints  may  be  mistaken 
for  arthritis  deformans  or  chronic  rheumatism.  In  younger  subjects 
the  same  condition  is  often  very  hard  to  dift'erentiate  clinically  from 
gonorrheal  osteo-arthritis  (see  page  170). 

Purulent  tuberculous  arthritis  is  generally  diagnosed  correctly 
only  after  incision. 

Treatment 

Bone  tuberculosis  calls  for  operative  interference  sooner  than 
does  joint  tuberculosis.  The  focus  must  be  exposed  and  scraped,  and 
the  cavity  packed  with  iodoform  gauze.  Abscesses  are  treated  by 
tapping  and  injection  (see  above)  or  incision  and  scraping. 

In  the  extremities,  immoliilization;  in  tuberculous  disease  of  the 
spine,  operative  interference  was  formerly  limited  to  the  treatment 
of  abscesses.     But  recent  operative  methods    {Hihhs)   allow  of  a 

197 


quicker  cure  with  much  better  result  and  no  angmlar  sinking  of  the 
spine,  as  was  formerly  essential  to  recovery. 

In  its  early  stages  tuberculous  arthritis  may  be  cured  by  immo- 
bilization by  means  of  extension  splints  or  plaster  of  Paris  casings. 
Conservative  treatment  should  always  he  adopted  in  the  early  stages. 

Hydrops  may  be  treated  by  repeated  puncture,  injection  of  iodo- 
form-glycerin  emulsion  and  immobilization  of  the  joint.  Recurrence 
is  common,  and  complete  restoration  of  function  seldom  occurs.  The 
joints  should,  therefore,  be  allowed  to  ankylose  in  the  most  useful 
position;  that  is,  extension  for  the  knee  and  flexion  for  the  elbow. 
When  abscesses  and  fistute  form,  and  when  an  extensive  focus  of 
bone  disease  is  shown  by  the  X-rays,  conservative  treatment  must  be 
abandoned,  at  least  in  adult  subjects.  Children  may  still  recover 
under  conservative  treatment  after  abscess  formation,  and  in  them 
resection  is  more  serious,  from  the  standpoint  of  functional  results, 
as  it  may  markedly  impair  the  growth  of  the  limb. 

In  fibrous  arthritis,  caries  sicca  and  white  swelling,  which  are 
more  frequent  in  adults,  resection  of  the  joint  should  be  performed 
as  early  as  possible,  to  prevent  muscular  atrophy.  In  the  shoulder 
joint  resection  gives  good  results;  but  in  the  knee  joint,  bony  anky- 
losis in  straight  position  is  the  only  possible  result. 

In  fungous  arthritis,  especially  in  young  patients,  operation  may 
be  limited  to  opening  the  joint  and  carefully  removing  all  tuberculous 
disease  (arthrectomy) .  The  capsule  of  the  joint  must  be  excised 
wherever  it  is  diseased,  and  tuberculous  foci  in  the  cartilage  and  bone 
removed  with  the  rongeur  and  curette.  In  young  subjects  typical 
resection  of  the  joint  is  to  he  avoided,  owing  to  interference  with 
the  growth  of  the  limb  by  extensive  removal  of  the  epiphyses. 

In  adults,  on  the  other  hand,  the  joint  may  be  resected  and  all 
diseased  parts  carefully  removed.  If,  after  resectioji  of  the  epiphy- 
sis, the  medullary  cavity  is  found  to  be  diseased,  it  must  be  scraped 
out.  Abscesses  and  fistulse  require  incision  and  scraping.  In  purulent 
arthritis  the  joint  must  be  freely  opened;  in  advanced  cases  resection 
is  necessary.  In  extensive  tuberculous  arthritis  with  tuberculous 
disease  of  the  neighboring  bones  and  soft  parts,  amputation  may  be 
necessary,  especially  in  old  people  (Fig.  130)- 

After  atypical  resection,  the  joint  must  be  packed  with  iodoform 
or  sterile  gauze.  After  a  typical  resection,  only  a  drain  is  left.  In 
both  cases,  it  is  immobilized  in  a  plaster  cast.  Immobilization,  despite 
the  muscular  atrophy  it  provokes,  must  be  kept  up  until  complete 
recovery. 

Joints  which  have  become  healed  in  abnormal  positions  may  be 

198 


Bockenheimer,  Atlas. 


Tab.  XCIX. 


Fig.  125.    Arthritis  tuberculosa  fungosa  -  Ankylosis  genus  fibrosa  -  Abscessus  frigidus. 


Rcbrnan  Company,  New- York. 


forcibly  corrected  under  an  anesthetic  when  the  ankylosis  is  fiJ)rous; 
but  there  is  dau.u'er  of  rupture  ol'  tlie  vessels  and  couseriuent  gan- 
grene,  especially  in  the  knee  joint,  Avhere  the  head  of  the  tibia  is 
always  in  a  position  ot  posterior  subluxation  (Fig.  127)  i'lid  threat- 
ens the  i)opliteal  vessels  in  case  of  sudden  straightening,  and  also 
when  tm  artery,  shortened  by  retraction,  is  suddenly  elongated 
(Fig.  132).  It  is  better  to  treat  fibrous  ankylosis  by  gradual  exten- 
sion; wliilc  bony  ankylosis  in  a  bad  ]Kisition  may  require  resection. 

in  addition  to  what  has  already  been  referred  to  in  the  text,  a  few 
special  points  of  clinical  interest  can  be  gleaned  from  the  examina- 
tions of  the  a]>]K'n(l('(l  iliiisti'ations. 


Fig.  125  shows  a  case  of  multiple  tuberculosis  of  the  joints, 
bones,  and  soft  ])arts,  associated  with  pulmonary  tuberculosis,  in  a 
young  individual.  There  is  a  fungoid  arthritis  of  the  ankle  joint, 
with  typical  ulcers,  and  thin,  greenish  discharge.  The  X-rays  showed 
a  primary  focus  in  the  astragalus.  The  foot  is  in  a  faulty  equinus. 
position.  The  knee  joint  was  the  seat  of  an  old  fibrous  arthritis  and 
is  ankylosed  in  a  right  angle  position.  There  was  also  an  old  healed 
hip  disease,  which  rendered  the  limb  useless.  The  thigh  was  flexed 
ajid  X-ray  examination  showed  destruction  of  the  upper  margin  of 
the  acetabulum  and  displacement  of  the  head  of  the  femur  onto  the 
ilium.  In  the  middle  of  the  flexor  surface  of  the  thigh  is  a  healed 
fistula  due  to  a  burrowing  abscess.  In  the  middle  of  the  extensor 
surface  of  the  thigh  is  a  clearly  visible  swelling  due  to  another  bur- 
rowing abscess,  (common  in  this  situation  in  tuberculosis  of  the  hip 
joint  or  of  the  vertebr89;  in  the  latter  ease  the  abscess  travels  along 
the  psoas  muscle).    Fluctuation  was  preseut,  but  the  skin  was  intact. 

The  ankle  joint  was  treated  by  free  scraping,  the  faulty  jiosition 
of  the  knee  corrected  under  anesthesia,  and  the  limb  ]iut  in  a  plaster 
of  Paris  cast. 

The  abscess  due  to  the  tuberculous  coxitis  was  evacuated  by  punc- 
ture and  injected  with  iodoform-glycerin.  Eesectiou  of  the  hip  joint 
was  postjxjiied  till  the  general  conditinn  of  the  patient  was  iiniu'oved. 

Fig.  126  shows  a  case  of  purulent  tuberculous  arthritis  of  the 

ankle-joint.  Owing  to  the  inflamnuitory  symptoms,  this  type  may  be 
mistaken  for  acute  pyogenic  arthritis;  and,  in  fact,  it  is  often  due 
to  a  mixed  infection. 

199 


Two  incisions  were  made  on  the  outer  and  inner  sides  of  the 
joint,  and  characteristic  thin  pus  mixed  with  fibrin  was  evacuated. 
The  joint  was  then  put  up  in  plaster  of  Paris.  Purulent  tuberculous 
arthritis  in  children  often  recovers  after  early  incision ;  but  there  is 
generally  some  stiffness. in  the  joints,  so  that  these  must  be  put  up 
in  the  most  suitable  position  for  future  use. 


Fig.  127  shows  a  case  of  old-standing  fibrous  tuberculous 
arthritis  of  the  knee  joint  with  bony  ankylosis,  as  shown  by  the 
X-rays.  Owing  to  neglect  of  prolonged  fixation  of  the  point  in  the 
straight  position,  flexion  contracture  with  backiuard  displacement  of 
the  tibia  (a  very  common,  almost  constant,  occurrence  in  tuberculous 
arthritis  of  the  knee;  already  referred  to  on  page  199,  and  which 
creates  considerable  difficulty  and  danger  to  the  popliteal  vessels  if 
simple,  forcible  straightening  is  attempted)  has  taken  place.  There- 
fore cuneiform  osteotomy  was  performed. 

Fig.  128  shows  a  white  swelling,  a  common  form  of  tuberculous 
arthritis  of  the  knee  in  adults.  It  belongs  to  the  fibrous  variety  (see 
page  196).  The  disease  was  of  several  months'  duration,  and  was 
associated  with  tuberculosis  of  the  lungs.  The  patient  attributed  the 
affection  of  the  knee  to  an  injury.  (In  tuberculous  arthritis  trauma 
often  has  a  localizing  influence  in  a  subject  already  harboring  a 
tuberculous  focus.)  The  X-rays  showed  lesions  of  the  bones,  as 
well  as  of  the  synovial  membrane — the  usual  combination  in  tubercu- 
losis of  the  knee  joint.    Eesection  and  arthrectomy  were  performed. 

A  swelling  somewhat  similar  in  shape  to  that  shown  in  Fig.  128, 
"but  more  distinctly  fluctuating,  occurs  in  the  rarer  cases  of  tubercu- 
lous hydrops,  the  simplex  form  of  tuberculous  joint  disease.  Effu- 
sion into  the  joint  often  precedes  the  arthritis  and  is  recognized  by 
hallottement  of  the  patella,  which  is  raised  from  the  femoral  condyles 
hy  the  fluid  in  the  joint.  The  fluid  is  generally  sero-fibrinous,  with 
numerous  free  "rice  bodies." 

Still  more  common  than  the  fibrous  form  is  fungoid  arthritis, 
which  may  go  on  to  suiDpuration  and  caiise  much  destruction  in  and 
around  the  joint. 

In  all  forms  of  tuberculous  arthritis  of  the  knee,  the  joint  is  in  a 
position  of  valgus  and  flexion,  which  makes  the  internal  condyle  of  the 
tibia  seem  hypertrophied  and  very  prominent.  There  is  much  atrophy 
of  the  muscles  of  the  leg  and  the  growth  of  the  latter  is  considerably 
retarded. 

200 


BockciilR-iiucr,  Alias. 


Tab.  C. 


Fit)'.  120.    Arthritis  tuberculosa-nuruienta. 


Fig.  12/.    Arthritis  tuberculosa  fibrosa 
Ankylosis  ossea  —  Subluxatio. 


Ucbinan  Conip.iny,  New-N'orU. 


Bockenheimer,  Atlas. 


Tab.  CI. 


Fig.  128.    Arthritis  tuberculosa   —  Tumor  albus. 


Rebma)!  Coiniiany,  New- York. 


Fig.  131  sliows  tin'  sjiccial  lyjic  of  InlitTculosis  seen  in  the  pha- 
lanfTt's  and  called  spina  ventosa.  , 

Tuberculosis  ol"  the  i)halanges  l)ef;iiis  in  the  nie(hilia  and  extends 
to  the  cortex  and  periosteum.  The  wliole  diaphysis  may  he  destroyed 
by  suppuration  and  caseation,  while  the  periosteum  produces  a  thin 
shell  of  new  bone.  The  bone  tlien  api)ears  swollen,  as  if  inflated, 
hence  the  name. 

The  disease  generally  alTeets  several  phalanges  of  several  fingers 
on  both  hands,  and  is  often  found  in  the  children  of  tuberculous 
parents.  The  destructive  process  is  more  severe  than  in  any  other 
form  of  tuberculous  osteitis,  several  phalanges  being  often  completely 
destroyed.  Fistula^  open  in  the  edematous  skin  and  discharge  caseous 
matter.  Growth  of  the  fingers  is  interfered  with,  so  that  there  often 
only  remains  deformed  stumps  after  the  disease  has  healed. 

Despite  the  very  characteristic  picture,  the  disease  is  often  over- 
looked, as  it  is  at  first  painless;  but  early  diagnosis  can  be  made  by 
the  X-rays,  which  show  the  changes  in  the  bone. 

Syphilitic  dactylitis  differs  in  causing  less  destruction  of  bone, 
and  in  the  usual  absence  of  suppuration  and  necrosis;  but  the  diag- 
nosis often  depends  on  other  signs  and  an  antecedent  history  of  syph- 
ilis or  tuberculosis. 

The  treatment  is  early  incision,  scraping,  and  bone  tx'ansplanta- 
tion,  to  ward  off  subsequent  deformity. 

Fig.  130  shows  a  case  of  tuberculosis  of  several  structures  of 
the  back  of  tfte  hand,  in  an  old  woman  suffering  from  advanced 
pulmonary  tubei-culosis.  A  swelling  gradually  developed  and  ex- 
tended on  the  back  of  the  hand,  limiting  finger  motion.  Two  typical 
tuberculous  ulcers  discharging  thin  pns  and  caseons  matter  developed 
on  the  back  of  the  hand.  Passive  movement  at  the  wrist  joint  was 
very  limited  and  caused  crepitation.  The  X-rays  showed  tubercu- 
lous disease  of  the  carpal  and   metacarpal  bones. 

At  operation,  tuberculosis  of  the  tendon-sheaths  was  also 
found.  'This  condition  is  more  frequent  in  the  upjier  extremity  (as 
are  all  tendon-sheath  diseases)  and  may  exist  independently  of  a 
bone  focus.  It  appears  either  as  fiihercidotis  luiqroma,  with  serofibri- 
nous fluid  and  rice  bodies  causing  crepitation  on  movement,  or  under 
the  fungoid  form,  with  s]ion,g}'  granulations  in  which  the  sinews  are 
imbedded. 

Tuberculosis  of  the  wrist  .ioint  in  old  people  is  often  so  extensive 
as  to  require  amjiutation.  Tn  the  present  case,  it  was  treated  by 
resection,  iodoform-glycerin  injections  and  a  plaster  cast.    Tubercu- 

201 


lous  tendovaginitis  is  treated  by  careful  scraping,  so  as  not  to  injure 
the  tendons.  <, 


Fig,  129  shows  an  extensive  case  of  tuberculosis  of  the  testicle 

and  epididymis,  in  a  patient  having  advanced  tuberculosis  of  the 
lungs.  The  skin  is  thin  in  several  i^laces  and  ulcerated  in  one  place. 
The  testicle  was  removed,  and  on  section  showed  miliary  nodules  in 
some  parts,  caseous  .foci  and  abscesses  in  others. 

Tuberculosis  of  the  testicle  is  usually  consecutive  to  similar  con- 
ditions of  the  prostate  and  seminal  vesicles,  but  it  is  always  consecu- 
tive to  another  pre-existing  tuberculous  focus  in  the  body.  (In  the 
case  of  Fig.  129  there  was  pulmonary  tuberculosis,  but  no  prostatic 
or  vesicular  lesions.) 

In  the  early  stages  hard  nodules  are  felt  in  the  epididymis.  Later 
on  the  testicle  is  involved;  the  nodules  become  soft  and  adherent  to 
the  skin,  which  breaks  down  and  forms  a  typical  ulcer  (Fig.  129).  In 
advanced  cases  there  may  be  several  scrotal  ulcers  and  fistuhe.  The 
spermatic  cord  is  usually  thickened  and  irregular;  the  seminal  ves- 
icles are  found  nodular  by  rectal  examination. 

Diagnosis 

The  diagnosis  is  sometimes  easy,  sometimes  very  difficult.  In  its 
•early  stage,  tuberculosis  may  be  mistaken  for  syphilis;  but  the  latter 
primarily  affects  the  testicle,  not  the  epididymis;  there  is  a  char- 
acteristic loss  of  the  special  sensitiveness  of  the  testicle  to  pressure; 
the  antecedent  history  and  the  Wassermami  reaction  may  give  con- 
firmatory evidence.  Malignant  growths  increase  more  rapidly;  the 
tuberculin  test  may  here  be  useful.  Acute  epididymitis  may  be  con- 
fused only  with  the  rare  acute  forms  of  testicular  tuberculosis. 
Chronic  epididymitis  is  recognized  by  the  antecedent  history  and 
the  progress  toward  regression,  not  caseation  or  fistulization. 


The  treatment  of  tuberculosis  of  the  testicle  is  general  and  local. 
The  general  treatment  includes  the  usual  hygienic  and  dietetic  pre- 
scriptions (very  important)  and  the  use  of  tuberculin,  which  is  bene- 
fieial  in  these  cases  {Walker,  Belfield,  Young).  The  best  local 
treatment  in  recent  cases  is  epididymectomy  (Keyes,  Jr.,  Barney). 
In  older  cases,  castration  may  be  required,  if  scraping  and  injections 
are  ineffectual. 


303 


UockciilR'iiiur   Atlas. 


Tnli.  Cll. 


Urliiunn  Conipniiy,  Now-Vork. 


BnckciilifitiuT,  Atlas. 


Tab.  cm. 


lie.  I'M),     rubciculosii  luaiius. 


Kebniaii  ("nnipaiiy,  NewA'oik. 


GANGRENES 

Figs.  132-141 


Burns 
Congelation 


Bockenheimer,  Atlas. 


Tab.  Cl\', 


O 


o 


Rebinan  Comp.iiiy,  New- York. 


GANGRENES 

Figs.  132  to  140,  inclusive,  show  couditioiis  caused  l)y  gangrene 

due  to  various  causes. 

Gans'rene  is  the  progressive  death  of  the  superficial  tissues  of 
the  body ;  while  the  word  necrosis  is  more  particularly  applied  to  the 
death  of  the  deeper  structures  (fascia,  muscle  and  bone).  But  this 
distinction,  which  dates  back  to  preantiseptic  days,  when  external 
gangrene  was  always  septic  and  the  deep  tissues  alone  could  die  asep- 
tically,  is  now  obsolete.  The  essential  process  of  gangrene  and  that 
of  necrosis  are  identical;  both  are  primarily  aseptic,  but  external 
gangrene  is  venj  often  modified  by  infection;  this  is  why  the  limits 
of  the  nosological  group  of  gangrenes  are  not  always  very  clear.  But 
gangrene  is  not  putrefaction,  though  both  conditions  are  often 
associated:  putrefaction  is  an  added  process,  a  complication  of 
gangrene. 

Primarily  aseptic  gangrene  is  due  to  direct  or  indirect  causes. 
Direct  causes  are  burns,  congelation  or  traumata.  Among  the  latter, 
crushing  injuries  and  contusions  are  the  most  dangerous  as  to  gan- 
grene. Long  continued  pressure  causing  ischemia  has  already  been 
spoken  of  under  ischemic  retraction  (Fig.  63) ;  it  is  a  powerful  cause 
of  gangrene  of  the  skin  (see  page  210)  and  of  the  internal  mucous 
membranes. 

Indirect  causes  are  vascular  lesions,  nervous  disturbances  and 
blood  alterations.  Any  vascular  lesion  that  results  in  the  shutting 
off  of  the  blood  supply  of  a  region  leads  to  gangrene.  Ligation  of  the 
main  artery  of  a  limb  was  a  frequent  cause  of  gangrene  in  preanti- 
septic days,  when  the  thrombus  was  infected  and  extended  much  far- 
ther than  it  does  in  aseptic  operations.  For  this  reason  the  danger  of 
gangrene  from  this  cause  is  much  smaller  nowadays,  but  it  still  exists, 
particularly  when  the  arterial  walls  are  diseased  (see  page  110  about 
the  efficiency  of  collateral  circulation  in  aneurysm).  Subcutaneous 
rupture  of  arteries  (Figs.  132  and  133)  I'emains  particularly  liable 
to  cause  gangrene. 

Embolism  of  an  artery  (e.g.  from  heart  disease)  is  attended  by 
sudden  and  extensive  gangrene  of  the  territory  supplied.  Throm- 
bosis in  diseased  arteries  is,  perhaps,  to-day,  the  most  important 
etiological  factor.     Senile  gangrene  is  due  to  arteriosclerosis:  the 

205 


loosened  intima  in  the  small  terminal  vessels  (and  also  in  some  of  the 
larger)  ijrovokes  thrombosis,  and  as  the  collateral  circulation  is  in- 
sui'ed  only  by  altered  and  sclerosed  channels,  gangTene  follows. 
Arteriosclerosis,  the  deficient  power  of  resistance  of  the  anatomical 
structures,  and  maybe  also  blood  alterations,  explain  diabetic  gan- 
grene (Fig.  140).  Carbolic  gangrene  (Fig.  135)  is  probably  due 
to  thrombosis  of  small  vessels. 

In  younger  peojDle,  obliterating  endarteritis  is  chiefly  due  to  syph- 
ilis: it  gives  rise  to  a  slowly  progressing  type  of  gangrene  (angio- 
sclerotic gangrene). 

Vaso-motor  constriction  of  the  blood-vessels  is  a  cause  of  gan- 
grene in  certain  nervous  diseases  (e.g.  Raynaud's  disease,  Fig.  139)- 
Gangrene  consecutive  to  subcutaneous  injection  of  adrenalin  is  prob- 
ably due  to  too  prolonged  ischemia  by  vaso-constriction.  The  same 
explanation  was  formerly  unreservedly  admitted  for  gangrene  fol- 
lowing the  administration  of  ergotin.  Now,  it  seems  that  blood  alter- 
ations may  play  a  part  in  this  case. 

About  gangrene  due  to  blood  alterations  little  definite  is  known. 

When  the  anatomical  process  consists  in  desiccation  of  the  tissues 
it  is  called  dry  gangrene  (Fig.  134) ;  when  it  ends  in  liquefaction 
from  the  invasion  of  jiutrefactive  bacteria,  it  is  called  moist  gan- 
grene (Figs.  132  and  134).  Dry  gangrene  may  change  to  moist,  and 
both  processes  may  occur  simultaneovisly  in  different  parts  of  the 
same  limb,  when  one  part  becomes  septic  and  the  other  does  not. 

Gangrene  due  to  arteriosclerosis  is  preceded  by  pain  in  the  affected 
part.  That  caused  by  syphilitic  endarteritis  is  often  heralded  in  by 
severe  intermittent  pain,  which,  in  the  lower  limbs,  causes  the  patient 
to  limp  (intermittent  claudication).  The  gangrene  of  Raynaud's 
disease  is  generally  preceded  by  paresthesia  and  disturbances  of  the 
thermic  sensil)ility. 

•  The  extent  of  the  gangrene  varies  according  to  the  cause ;  it  may 
be  circumscribed  (after  local  applications,  such  as  carbolic  acid),  or 
progressive  (after  embolism).  In  both  forms  the  dead  tissue  becomes 
sejiarated  from  the  living  by  a  zone  of  demarcation.  The  zone  of 
demarcation  forms  a  groove  filled  with  granulation  tissue  (Fig.  132). 
It  may  be  circular  (Fig.  135)  or  irreg-ular  (Figs.  133  and  134). 
■Ill  the  early  stage  of  dry  gangrene  the  condition  resembles  that 
of  ischemic  muscular  contracture  (Fig.  63),  especially  Avhen  the  con- 
dition is  due  to  plugging  of  the  blood-vessels.  The  skin,  at  first  cold 
and  pale,  next^dotted  with  bluish  patches  arrayed  irregularly,  finally 

20& 


becomes  div,  slinnikfii  .iinl  ii.iiclmient-like.  Tn  tlie  exlromities  tlie 
perii)lionil  parts  aic  llcxcil  and  iiiiinovahle.  Tlie  skin  l)ecoiiies  grad- 
ually yello\visli-liri)\vii  and  liiially  hlack  (Fig.  133).  All  the  subjacent 
structures  may  uiulers^u  dry  atrophy.  The  dead  tissue  is  gradually 
sejiarated  by  the  zone  of  demarcation,  and  the  whole  of  an  extremity 
may  thus  nndergo  s|)()ntaneous  sei)aratioii. 

While  ill  dry  gangrene  there  is  diuiiHution  in  xolnnic  and  chaniiig 
of  the  affected  part,  in  moist  gangrene  there  is  increase  bi  volume, 
due  to  preceding  edema.  In  moist  gangrene  there  is  always  more  or 
less  liquefaction  and  putrefaction,  due  to  bacteria.  The  skin  is  cold 
and  moist,  and  the  ei)idermis  becomes  raised  in  Imlhe  containing 
lildod-staincd  llni<I.  After  rupture  of  the  bulhe  the  skin  is  reddish- 
brown  (Fig.  109).  Finally  the  tissues  become  disintegrated  and 
the  odor  emitted  is  liorribly  foul;  lymphangitis,  lymphadenitis  and 
general  infection  then  follow. 

A  deep  groove  of  demarcation,  separating  the  dead  from  the 
living  tissue,  also  forms  in  moist  gangrene,  and  spontaneous  elimina- 
tion may  occur  if  the  patient  does  not  succumb  to  general  infection. 
In  less  extensive  cases  of  moist  gangrene  we  can  wait  for  the  estab- 
lishment of  this  line  of  demarcation;  but  the  gangrenous  part  must 
be  removed  if  there  are  chills  and  high  temperature,  else  the  patient 
would  die  of  acute  toxemia  caused  by  the  resorption  of  poisonous 
products  from  tlie  gangrenous  ]:>art. 

Diaijnosis  and  prognosis 

The  appearance  of  gangrene,  when  fully  developed,  is  so  char- 
acteristic that  it  can  hardly  be  mistaken  for  any  other  condition.  The 
two  forms  of  gangrene  are  also  sharply  defined  from  each  other.  Dry 
gangrene  might  lie  mistaken  for  burns  of  the  third  or  fourth  degrees, 
if  signs  of  the  first  and  second  degree  of  burn  were  not  always  ]>res- 
ent  in  the  neighborhood,  and  if  the  anamnesis  was  not  always  so  cleai*. 

j\Ioist  gangrene  might  lie  mistaken  for  putrefactive  jihleginon, 
especially  progressive  gaseous  idilegmon  (Fig.  109).  if,  iu  the  latter, 
the  signs  of  general  iid'i'ctinn  were  not  present  at  a  vciv  early 
stage.  The  history  and  a  thorough  examination  will  not  only  estab- 
lish the  diagnosis,  but  in  most  cases  will  decide  the  cause  of  the 
gangrene. 

The  jirognosis  natnially  de])ends  on  the  cause  and  on  the  extent 
of  the  gangrene.  Angiosclerotic  (endarteritic)  gangTene  spreads 
very  slowly;  it  may  remain  stationary;  or  i)arts  which  appeared  to 
be  affected  mav  recover.     Plugging  of  a  large  vessel  causes  extensive 


gangrene  of  the  part  supplied  by  the  vessel,  and  the  prognosis  is  not 
favorable.  Diabetic  gangrene  and  senile  gangrene  are  characterized 
by  their  progressive  course.  Gangrene  is  more  extensive  when  there 
is  much  edema. 


In  threatening  arteriosclerotic  gangrene,  the  limb  should  be 
raised  and  wrapped  in  wool :  hot-air  treatment  is  useful  for  the  pains : 
alcohol  should  be  avoided.  If  a  syphilitic  origin  is  suspected,  mercury 
and  iodides  should  be  freely  given;  salvarsan  is  contraindicated  in 
marked  cardiovascular  degeneration. 

The  gangrenous  part  should  be  covered  with  aseptic  dressings. 
If  surgical  interference  is  not  urgent,  it  is  better  to  wait  for  the  zone 
of  demarcation  to  appear  and  then  to  perform  amputation  in  the 
most  conservative  way  possible.  But,  sometimes,  in  moist  gangrene 
of  an  extremity,  early  removal  is  indicated  in  order  to  forestall  gen- 
eral sepsis.  In  diabetic  gangrene  (see  page  213)  high  amputation  is 
often  necessary.  The  same  was  true,  not  long  ago,  of  most  cases  of 
embolic  gangrene.  Now  arteriotomy  has  been  performed  for  the  con- 
dition (Steivart).  While  the  clot  almost  invariably  reforms  in  the 
point  operated  on,  the  operation  may  give  the  collateral  circulation 
a  little  more  time  to  develop  and  lessen  the  area  of  mortification. 

In  amputation  for  arteriosclerotic  gangrene  the  tourniquet  is  not 
to  be  used,  as  it  may  cause  thrombosis  at  the  point  of  application  and 
further  gangrene  of  the.  stump.  If  the  vessels  in  the  stump  only 
bleed  slightly,  this  shows  that  they  also  are  already  diseased  and 
that  the  gangrene  will  probably  extend  further.  The  veins  in  the 
amputation  stump  bleed  freely,  owing  to  the  absence  of  the  sustaining 
arterial  vis  a  tergo.  After  amputation  any  pressure  of  the  dressings 
is  to  be  avoided. 

Arterio-venous  anastomosis  of  the  femoral  artery  and  vein  has 
been  performed  about  forty-five  times  in  case  of  arteriosclerotic  gan- 
grene {Hubbard  and  others)  in  the  hope  of  reversing  the  circulation 
in  the  limb.  Unfortunately,  this  reversal  is  not  obtained,  and,  barring 
exceptional  cases  {Wieting,  Ballance,  Davies),  the  operation  has  not 
yielded  any  permanent  benefit.  However,  it  is  but  fair  to  add  that  it 
was  employed  only  as  a  last  resort  in  otherwise  hopeless  cases, 
generally  by  men  not  sufficiently  trained  in  vascular  surgery,  and  that 
it  holds  better  promises  in  cases  where  gangrene  is  simply  impend- 
ing, instead  of  actually  existing.  (See  about  Raynaud's  disease,  page 
216.) 

208 


Bockenheimer,  Atlas. 


Tab.  CV. 


Fie-  133.   Oanoraena  sicca  brachii  -  Mumificatio. 


Rebman  Comnanv.  New-York. 


Fig.  132  shows  a  case  of  moist  gangrene  of  the  foot  'lue  to  a 
special  ami  iiiteresting  origin,  as  it  devoloptMl  alter  I'orrilile  correc- 
tion of  flexion  contracture  due  to  tuberculosis  of  the  liii)-.joiut,  a  con- 
tingency already  alhided  to  on  page  199. 

Soon  after  this  operation  the  toes  became  cold,  blue  and  flexed, 
and  finally  black.  As  the  gangrene  was  limited  to  the  anterior  por- 
tion of  the  foot,  it  is  probable  that  the  injury  implicated  the  intima 
only  and  was  not  a  complete  rupture  of  the  femoral  artery,  and  that 
gangrene  was  due  to  thrombosis  of  the  vessel.  In  the  figure,  necrotic 
bone  is  seen  to  protrude  from  fistuhi?  (first  and  fifth  toes).  In  the 
sole  of  the  foot  is  seen  a  wide,  granulation  covered  zone  of  demarca- 
tion separating  the  gaugreuous  [)art  from  the  healthy  tissues  behind. 


Fig.  133  shows  a  typical  case  of  dry  gangrene  or  mummification 

of  the  arm,  affecting  all  the  tissues.  The  fingers  are  contracted 
and  blackish-brown  in  color.  The  skin  is  hard.  In  the  forearm  com- 
mencing gangrene  is  seen  in  the  yellow,  leathery  skin.  The  line  of 
demarcation  is  seen  as  a  red  zone  of  granulation  tissue,  separating 
the  dead  from  the  healthy  parts.  After  the  line  of  demarca- 
tion had  extended  all  ai'ound  the  limb,  amjratation  throngh  the  arm 
"was  performed. 

The  cause  of  gaiigi'pue  in  this  case  was  of  a  nature  similar  to  that 
of  the  case  of  Fig.  132,  namely,  an  arterial  tear  during  an  operation 
for  an  articular  condition  accompanied  by  periarticular  sclerosis  and 
retraction.  It  was  due  to  rupture  of  the  axillary  artery  during  an 
operation  for  reduction  of  an  old  dislocation  of  the  shoulder.  In  such, 
cases  bloodless  reduction  is  generally  impossible  and  may  cause  rup- 
ture of  the  artery.  But  this  disadvantage  also  applies  to  reposition 
by  open  operation,  for  the  displaced  vessels  are  liable  to  become  dam- 
aged by  pressure  of  the  dislocated  head  of  the  humerus  and  are 
easily  torn  during  reduction  of  the  dislocation.  This  accident  may  be 
avoided  by  resection  of  the  head  of  the  humerus,  after  carefully  dis- 
secting free  the  artei'v,  wliii-li  is  geiierallv  miited  to  it. 


Fig.  134  shows  a  case  of  moist  gangrene  of  the  skin  with 
necrosis  of  the  abdominal  fascia.  The  necrotic  part  of  the  skin  is 
Separated  by  a  zone  of  deniarcatinu  from  the  healthy,  soniowhat  red- 
dened and  inflamed  skin  around  it.  It  is  still  liniily  altafhcil  to  the 
subjacent  structures.    In  some  places  the  skin  has  soparatod,  expos- 

20D 


ing  the  abdominal  fascia,  the  yellowish  color  of  which  shows  that  it 
already  has  undergone  necrosis.  The  borders  of  the  ulcer  were  under- 
mined, and  it.  discharged  fetid  pus. 

In  this  case  the  gangrene  was  caused  by  a  subcutaneous  injection 
of  salt  solution,  given  to  a  patient  in  a  state  of  collapse.  Gangrene 
of  the  skin  may  occur  after  injection  of  large  quantities  of  salt  solu- 
tion when  the  injection  is  made  intracutaneously  instead  of  subcu- 
taneously,  or  when  the  fluid  is  too  hot. 

The  ulcer  became  clean  under  dressings  of  peroxide  lotion;  the 
gangrenous  skin  and  necrotic  fascia  were  shed  spontaneously,  the 
edges  of  the  fascia  and  the  skin  were  sutured  separately,  and  primary 
union  took  place. 

The  skin,  being  the  most  superficial  part  of  the  body,  is  exceedingly 
liable  to  injuries  which  may  cause  gangrene  of  external  origin.  Long- 
continued  pressure,  especiallj^  in  places  situated  over  the  bones,  may 
cause  gangrene  of  the  skin.  In  this  way  gangrene  may  be  caused  by 
the  pressure  of  tight  bandages  or  splints  (see  ischemic  paralysis, 
Fig,  63  and  page  83) ;  also  by  a  displaced  piece  of  bone  in  fractures; 
by  pressure  on  the  outer  side  of  the  foot  in  pes  varus ;  by  tight  sutures, 
e.g.  after  amputation  of  the  breast  which  leaves  a  wide  space  to  be 
closed  (Fig.  55  and  page  75). 

Uncleanliness,  loss  of  consciousness,  nervous  diseases  (tropho- 
neuroses, syringomyelia,  hemiplegia,  paraplegia,  tabes),  cachexia, 
diabetes,  typhoid  fever,  osteomyelitis,  phlegmonous  inflammation, 
general  infection  and  comatose  conditions,  all  predispose  to  gangrene, 
which,  in  emaciated  persons,  may  become  very  extensive.  Gangrene 
of  the  skin  caused  by  the  pressure  of  edema  and  gaseous  formation 
in  the  tissues  has  already  been  mentioned  (Figs.  91  and  109)-  After 
operations,  gangrene  of  the  skin  (bed-soi-es)  may  occur  over  the  heels, 
buttocks,  spinous  processes,  shoulder  blades  and  back  of  the  head, 
if  care  is  not  taken  to  change  the  position  of  the  patient  and  apply 
soft,  smooth,  protective  coverings. 

Gangrene  of  the  skin  begins  with  pain  and  redness;  then  slight 
swelling  and  blue  discoloration;  finally,  raising  of  the  epidermis  in 
bullse.  The  epidermis  then  separates,  leaving  exposed  the  corium, 
which  is  at  first  greenish-yellow,  afterward  blackish-brown  and  leath- 
ery. At  the  edge  of  the  gangrenous  part  the  skin  becomes  inflamed, 
and  by  the  formation  of  pus  and  granulation  tissue  a  gTitter-shaped, 
often  circular  zone  of  demarcation  is  gTadually  formed.  The  more 
severe  the  injury,  the  deeper  is  the  gangrene,  so  that  subcutaneous 

310 


IJnckeiilieimcr,  Atlas. 


Fig.  134.    Qangraena  luunida  cutis  -   Necrosis  fasciae  —   Ulcus  dccubitale. 


Kebniaii  Company,  Nc\v-^*ork. 


Bockenheimer,  Atlas. 


Tab.  evil 


Fig.  135.    Gangraena  carbolica. 


Rebman  Company,  New-York. 


tissue, fascia  (Fig.  134).  imisclcs  and  Ikhic  iiia\  Ix'coine  necrosed  and 
cast  off. 

After  sei)aralii)n  ol'  llic  .yaii.nronous  i)art  tliere  is  left  a  decubHal 
ulcer  covered  witli  slimy,  uroenisli-yeilow  connective  tissue  shreds 
and  iV'lid  jius.  A  neg'lected  decubital  ulcer  may  j2;ive  rise  to  extensive 
putrid  inflammation  or  gaseous  jjlilogmon,  as  the  pus  always  contains 
puti'ef active  bacteria,  especially  when  situated  over  the  sacrum,  as 
it  then  is  always  infected  from  the  feces.    Erysipelas  may  also  occur. 

Gangrene  of  the  skin  may,  in  many  cases,  be  prevented,  or  at 
any  rate  limited,  by  prophylactic  treatment.  Decubital  ulcers  (bed- 
sores) may  be  prevented  by  ajjplications  of  spirit  of  camphor  and 
dusting  powder  to  the  skin  of  the  parts  exposed  to  pressui'e,  by  air 
cushions  and  frequently  changing  the  patient's  position.  If  the  skin, 
is  discolored  an  ointment  dressing  should  be  applied,  and  this  should 
be  changed  if  tlic  patient  complains  of  pain.  As  pain  also  sul)sides  in 
a  few  days  under  a  dressing,  removal  of  the  latter  is  often  neglected, 
and  when  it  is  done  there  may  be  gangrene  down  to  the  bone.  In 
emaciated  patients,  therefore,  the  bony  prominences  should  be  well 
padded,  the  skin  disinfected  before  applying  the  dressing,  and  the 
latter  changed  frequently. 

If  gangrene  has  developed,  the  skin  must  be  protected  against 
infection  by  a  dressing.  Separation  of  the  gangrenous  part  may  be 
hastened  by  moist  dressings  with  2%  boric  acid  or  3%  peroxide  solu- 
tion, applied  several  times  daily.  Forcible  removal  of  the  gangrenous 
pai'ts  while  they  still  are  firmly  adherent  is  not  advisable;  they  should 
be  trimmed  off  with  scissors  when  almost  completely  loose.  The 
ulcer  may  be  treated  with  moist  dressings  or  ointments,  and  with 
caustics  when  granulations  have  sprung  up  (see  Fig.  55  for  the 
treatment  of  granulating  wounds  with  balsam  of  Peru,  red  salve  and 
skin-grafting,  ]3age  75).  After  extensive  gangrene  of  the  skin,  the 
space  may  be  closed  l)y  undermining  the  surrounding  skin  and  sutur- 
ing; or,  if  this  is  impossible,  by  a  plastic  operation  by  means  of 
pedunculated  flajis. 


Fig.  135  shows  a  case  of  carbolic  gangrene  caused  by  dressings 
appliiMl  to  a  wound  in  the  finger.  The  end  of  the  latter  became  white 
and  the  ei)idermis  was  destroyed  as  far  as  the  carbolic  acid  dressing 
extended,   exposing  the  corium.     The  ]iatient  suffered  severe  jiain 

and  had  lut  feeling  in  the  tip  ol'  the  finger,  which  gradually  het^ame 
black  and  shrunken.     As  shown  in  the  figure,  tliei'e  was  a  total  slough- 


ing  of  the  terminal  phalanx,  while  the  greenish-yellow  color  at  the 
junction  of  the  terminal  with  the  middle  phalanx  indicates  commenc- 
ing gangrene.  In  the  middle  of  the  second  phalanx  there  is  a  wide 
zone  of  granulation  tissue  corresponding  to  the  line  of  demarcation. 
Severe  pain  in  the  finger  was  due  to  thrombosis  of  the  terminal 
arteries  caused  by  carbolic  acid.  Later  on  there  was  anesthesia  in 
the  finger  due  to  alterations  of  the  sensory  nerves. 

Moist  dressings  were  applied,  and  in  a  few  weeks  a  groove  of 
demarcation  extended  down  to  the  bone.  In  the  peripheral  part 
gangrene  spread  to  the  fascia,  muscles,  tendons  and  bone.  Healing 
took  place  after  exarticulation  at  the  interphalangeal  joint. 

It  must  be  borne  in  mind  that  even  1%  carbolic  solution,  after  a 
few  hours'  application  only,  may  cause  sloughing  of  the  skin  and 
deep  necrosis  by  thi'ombosis  of  the  vessels.  Certain  individuals  ap- 
pear to  be  predisposed  to  gangrene  after  fomentations  with  carbolic 
acid  (and  sometimes  lysol),  especially  when  gutta  percha  tissue  is 
placed  over  the  dressing,  preventing  evaporation.  After  a  short 
application  the  skin  may  recover. 

Contused  wounds  must  never  be  disinfected  with  carbolic  dress- 


Fig.  140  shows  incipient  gangrene  of  the  right  foot  in  a  man 
of  56,  suffering  from  diabetes  and  arteriosclerosis  for  some  years. 
The  toes  are  bluish-red  in  some  parts,  grayish-black  in  others,  while 
the  dorsum  of  the  foot  is  red.  The  skin  was  pale  and  cold.  The 
discoloration  appeared  in  the  course  of  a  few  hours,  and  in  a  few 
days  extended  to  the  ankle  joint.  Moist  gangrene  spread  rapidly 
from  the  toes,  and  lymphangitis  extended  up  the  leg. 

The  X-rays  showed  numerous  calcareous  deposits  in  the  interior 
and  posterior  tibial  arteries.  Amputation  was  performed  above  the 
knee  joint,  after  the  sugar  had  been  reduced  from  5  to  2%  by  three 
days'  treatment  of  the  diabetes.  After  operation  the  sugar  dimin- 
ished still  further,  and  the  temperature  fell — two  favorable  signs. 
Secondary  suture  of  the  stump  was  performed  on  the  fifth  day  and 
the  wound  healed  in  four  weeks.  After  general  treatment  the  sugar 
disappeared  from  the  urine. 

The  figure  also  shows  other  changes.  On  the  inner  side  of  the 
foot  over  the  metatarsophalangeal  joint  is  a  large  corn,  and  another 
on  the  fifth  toe.  The  nail  of  the  great  toe  is  affected  with  onychogry- 
posis,  a  common  condition  in  old  people  who  neglect  their  feet. 

212 


We  already,  several  times  had  oceasion  to  lay  stress  on  tlie  im- 
portance of  diabetes  as  regards  septic  conditions. 

Gangrene  is  frequent  in  diabetics.  Dry  gangrene  may  develop 
suddenly  in  the  lower  extremities  when  there  is  concomitant  arterio- 
sclerosis. The  whole  leg  may  be  affected  owing  to  thrombosis  of  the 
popliteal  artery.  The  first  symiitoms  are  those  of  arteriosclerosis: 
higli  blood  ]iressure,  hardness  of  arteries  (radial,  temporal),  numb- 
ness and  tiii,i;'liii,n'  sciis.-itioiis  in  the  toes:  later  the  ;i|)])earanf'e  is  that 
shown  in  Fig.  140. 

In  this  stage  tiiere  are  often  severe  neuralgic  pains,  while  the 
general  condition  of  the  patient  is  impaired  by  increase  of  sugar  in 
the  urine,  sleeplessness,  headache  and  exhaustion.  In  old  diabetics 
with  dry  gangrene  of  the  toes  demarcation  may  take  several  months 
to  develop.  Dry  gangrene  may  always  change  to  moist,  the  latter 
progressing  more  rapidly. 

Diagnosis  iind  Prognosis 

Diagnosis  of  diabetic  gangrene  is  made  by  the  search  for  sugar 
in  the  urine,  which  must  be  undertaken  in  all  cases  of  pyogenic  in- 
fection. Diagnosis  of  arteriosclerosis  is  made  by  the  blood  pressure 
test  and  palpation  of  the  hardened  arteries;  sometimes  by  the  X-rays 
in  case  of  marked  calcification. 

In  diabetic  gangrene,  the  prognosis  is  bad;  as  to  life,  it  depends 
chiefly  on  the  amount  of  sugar  and  the  response  to  antidiabetic  treat- 
ment. As  to  the  limitation  of  the  damage  caused  by  gangTene,  it  also 
depends  on  the  extent  of  the  arteriosclerosis  and  the  sufficiency  of  the 
collateral  circulation. 

Treatment 

Prophylaxis  consists  in  early  diagTiosis,  antidiabetic  treatment, 
and  measures  that  can  cheek  the  progress  of  arteriosclerosis. 

Once  gangrene  has  set  in,  the  general  principles  of  treatment  of 
gangrene  (see  page  208)  are  applicable. 

Active  (hot  air  or  bath)  hyperemia  (Stetten)  so  improves  circula- 
tion that  conservative  treatment  becomes  sufficient  in  most  cases  and 
yields  far  better  results  than  early  or  high  amputation.  Passive  hy- 
peremia is,  of  course,  absolutely  contraindicated. 

In  dry  gangrene  it  is  best  to  wait  for  demarcation,  unless  exten- 
sive arteriosclerosis  is  present.  If,  however,  the  popliteal  artery  is 
pulseless,  ami)utation  of  the  leg  is  the  only  remedy.  If  there  is  no 
arteriosclerosis,  the  gangrene  may  slowly  extend  for  months.    \Vheu 

213 


demarcation  is  complete  amputation  may  be  performed  directly  above 
the  line  of  separation.  Before  demarcation  the  parts  should  be  treated 
with  dry  aseptic  dressings  (moist  dressings  cause  putrefaction),  and 
be  suspended.  In  slowly  extending  moist  gangrene  demarcation  may 
be  waited  for  if  the  temperature  does  not  remain  high.  In  rapidly 
extending  moist  gangrene  with  high  temperature  early  amputation 
is  indicated  some  distance  above  the  gangrene.  In  gangrene  of  the 
lower  extremity  with  arteriosclerosis  it  is  better  to  amputate  through 
the  thigh;  for  the  flaps  after  amputation  through  the  leg  are  badly 
nourished  even  in  healthy  individuals,  and  in  diabetics  they  are  liable 
to  slough  off.  Amputation  through  the  thigh  is  best  performed  above 
the  condyles  or  through  the  epiphyseal  line.  Epiphyseal  stumps  have 
considerable  supiDorting  power.  As  a  rule,  amputation  may  be  con- 
servative in  slowly  progressing  cases  which  are  not  complicated  by 
phlegmonous  inflammation,  arteriosclerosis  or  high  temperature.  On 
the  other  hand,  rapidly  extending  gangrene  complicated  by  arteri- 
osclerosis and  phlegmon  always  requires  high  amputation.  (About 
arterio-venous  anastomosis,  see  page  208). 

Diabetics  with  gangrene  of  the  lower  limbs  are  always  poor  sur- 
gical risks.  Not  over  50%  recover  after  operation,  and  diabetic  coma 
is  a  frequent  complication  after  anesthesia.  Lumbar  anesthesia  is 
useful  when  it  <vorks  well:  infiltration  anesthesia  is  contraindicated, 
as  it  causes  inflammation  of  the  weakened  tissues.  Gas-oxygen  anes- 
thesia is  probably  the  best. 

When  the  vessels  are  sclerosed,  hemostasis  during  the  operation 
should  be  secured  by  digital  pressure  only,  as  the  application  of  the 
tourniquet  may  cause  thrombosis.  The  wound  should  be  dressed  with 
sterile  gauze;  iodoform  and  in  general  all  antiseptics  are  contra- 
indicated  on  account  of  the  danger  of  toxic  phenomena.  Primary 
suture  of  the  flaps  should  not  be  attempted,  and  these,  therefore, 
should  be  made  larger  than  usual.  Secondary  suture  may  be  per- 
formed after  a  few  days  if  the  progress  of  the  case  is  satisfactory. 
Ligatures  must  not  be  applied  too  tightly  to  vessels  affected  with 
arteriosclerosis,  lest  the  coats  of  the  vessel  give  way  and  secondary 
hemorrhage  should  result.  The  operation  must  be  performed  under 
the  strictest  aseptic  precautions,  as  diabetic  tissues  are  easily  in- 
fected, and  osteomyelitis  may  occur  in  the  bone  stump  or  phleg- 
monous inflammation  in  the  soft  parts.  Ulceration  of  the  stump  is 
common  after  healing.  Antidiabetic  treatment  must  be  vigorously 
pushed  during  all  the  time.  Incipient  diabetic  coma  may  be  cured  by 
intravenous  infusions  of  5%  sodium  bicarbonate  solution. 

214 


Fig.  139  shows  a  perforating  ulcer  of  the  foot  over  tlie  head  of 
tliL'  third  iiit'tatarsal  liniic;  tiic  uiiiiltn-iiiis  is  fissured  and  tliickeiied 
arduiul  the  small  ulcer,  which  is  covered  with  granulations  and  from 
wliic'h  a  necrosed  piece  of  fascia  is  seen  to  protrude. 

The  peripheral  part  of  the  foot  showed  the  diffuse  bluish-red 
discoloration,  charactoristic  o£  Raynaud's  disease,  wliich  existed 
also  symmetrically  dii  the  other  foot. 

Perforating  ulcer  of  the  foot  is  of  troiilunicurdtic  ori.nin  and 
due  to  disease  of  the  nervous  system.  It  orciirs  in  tahes,  syringo- 
myelia, certain  forms  of  spina  bifida  (Figs.  143  and  144),  and  also 
in  diseases  where  sensation  is  lost  in  the  lower  extremities.  Owing 
to  the  loss  of  sensation,  the  patient  does  not  notice  the  injury  to  the 
sole  of  the  foot  caused  by  pressure,  and  in  this  way  a  trophoneurotic 
ulcer  develops,  characterized  by  hard  borders  due  to  the  horny  epi- 
dermis which  is  normally  present  in  the  sole  of  the  foot.  These 
ulcers  may  also  develop  on  the  outer  border  of  the  foot  in  cases  of 
paralytic  pes  varus  (Fig,  143).  Some  authors  attribute  the  con- 
dition to  disease  of  the  blood-vessels  {arteriosclerosis,  endarteritis 
obliterans)  as  well  as  to  trophoneurotic  disorder,  and  in  many  cases 
both  conditions  are  probably  present.  That  the  blood-vessels  play 
a  part  in  the  pathogeny  of  perforating  ulcer  is  supported  by  the  fact 
that  this  condition  is  often  met  with  in  sypliilities  and  alcoholics  with 
vascular  degeneration. 

The  ulcer  begins  as  a  hard,  horny  thickening  of  the  epidermis 
over  the  heads  of  the  third  or  fifth  metacarpal  bones,  somewhat  re- 
sembling a  corn,  but  more  extensive.  The  epidermis  becomes  fissured 
and  finally  ulcerated  in  the  centre.  The  ulcer  is  characterized  by  its 
tendency  to  extend  deeply,  and  by  its  persistency  in  spite  of  all  kinds 
of  treatment.  The  disease  is  essentially  chronic  and  leads  to  de- 
struction of  muscles,  tendon-sheaths,  bones  and  joints,  by  continuous 
crateriform  extension  of  the  ulcer  into  the  deeper  tissues.  The  epi- 
dermis always  remains  tliickencd  at  the  border  of  the  ulcer,  and  is 
sometimes  undermined.  The  visible  surface  of  the  ulcer  is  .small  and 
is  covered  with  flabby  granulation  tissue.  Necrotic  slu'eds  often  pro- 
trude, indicating  extensive  destruction  of  the  fascia  and  tendons. 
There  is  often  loss  of  sensation  in  the  skin  for  some  distance  around 
the  ulcer.  As  a  rule  there  is  little  pain,  but  sometimes  paresthesia. 
The  general  health  may  suffer  from  prolonged  suppuration,  or  the 
condition  may  be  aggravated  by  acute  progressive  phlegmonous  in- 
flammation. 

215 


Raynaud's  disease — whicli  is  sometimes  called  gangrene,  but 
T^etter  local  asphyxia,  as  it  onlj'  consists  in  the  first  stage  of  gan- 
grene— is  usually  symmetrical,  and  affects  the  feet  more  often  than 
the  hands.  After  a  short  premonitory  stage  during  which  the  digits 
become  cold  and  white  (vaso-motor  constriction),  the  tips  of  the 
fingers  or  toes  become  dark-purple  and  the  proximal  parts  red  (vaso- 
motor paralysis).  The  disease  is  due  to  vaso-motor  disturbance  de- 
pending on  disease  of  the  peripheral  or  central  nervous  systems.  The 
symptoms  consist  in  paresthesias  and  disturbance  in  the  temperature 
sense,  and  pain  on  changes  of  temperature. 

Diagnosis   and  treatment 

A  beginning  perforating  ulcer  may  be  mistaken  for  a  corn  com- 
plicated by  a  mucous  bursa  and  central  fistula  (Figs.  64  and  99) ; 
but  the  latter  does  not  extend  so  deeply. 

Syphilitic  and  tuberculous  ulcers  are  recognized  by  their  usual 
characters,  already  mentioned  (pages  180  and  189) ;  besides  they  are 
rare  in  the  sole  of  the  foot ;  the  location  of  perforating  ulcer  is  char- 
acteristic. 

Raynaud's  disease  may  be  confounded  with  the  early  stages  of 
other  forms  of  gangrene  (Figs.  132,  133  and  140),  or  frostbite 
(Fig.  137) ;  but  the  changes  in  Raynaud's  disease  are  diffuse  and 
symmetrical. 

Even  in  the  early  stage  of  perforating  ulcer,  removal  of  the  cal- 
losity and  necrosed  tissue  gives  little  result.  In  the  later  stages  no 
treatment  is  very  efficient.  The  wound  must  be  protected  from  in- 
fection. Partial  amputation  of  the  foot  (tarso-metatarsal  exarticula- 
tion  in  the  case  of  Fig.  139)  is  sometimes  the  only  resource,  but  the 
ulcer  may  recur  on  the  stump.  The  internal  administration  of  iodides 
is  useful,  and  so,  perhaps,  would  be  salvarsan  treatment  in  those  cases 
in  which  a  syphilitic  or  parasyphilitic  etiology  is  likely.  Several 
successes  have  been  claimed  (especially  by  French  surgeons)  after 
elongation  of  the  plantar  nerves. 

Raynaud's  disease  is  perhaps  sometimes  of  syphilitic  origin  and 
would  be  benefited  by  antisyphilitic  treatment.  Avoidance  of  expos- 
ure to  cold  is  necessary:  hot-air  hyperemia  and  massage  are  useful. 

Arterio-venous  anastomosis  has  been  resorted  to  several  times  for 
Raynaud's  disease.  Bernheim  recently  published  a  very  remarkable 
case  in  which  he  successively  performed  the  operation  on  all  four 
limbs,  with  perfect  success  each  time.  As,  in  most  cases,  Raynaud's 
disease  is,  as  set  forth  above,  a  menace  of  gangrene  rather  than 

216 


Bockenheinier,  Atlas. 


Tab.  CVIII. 


Fig.  136.     Combuslio  er)'tliematos;i  —  bullosa  —  escharolica. 


Rebman  Coiiipanj',  New-York, 


actual  fi'aii^Teuo,  siood  rosults  nii;;lit  lie  cxiiiM-tcd  rr<iiii  this  opcratiou 
(sec  iKi.i>-c  liOy). 


Fig.  136  simws  all  I'mir  degrees  of  burns  caused  li\-  red-hot  metal, 
which   remained   loun'cr  in  eoiitnet  with  sdimi'  parts  than  dUicm'S. 

i'lic  first  degree  is  chai  acterized  hy  active  iiyporemia,  reddening 
and  swelling  of  the  skin  ;  the  second,  hy  the  raising  of  (he  e|)iderniis 
in  blisters  liy  exudation  of  lymph  hetween  said  epiderniis  and  the 
corinin;  the  lilisters  c(uitaiii  yellow,  clear  fluid  and  develop  within 
'lA  hours.  The  third  degree  is  aeeompanied  l)y  destruction  of  tlie  epi- 
dermis and  coriuni;  gangrene  of  the  skin  results  from  dehydration 
of  the  tissues,  coagulation  of  albumin,  and  acute  thrombosis  of  the 
blood-vessels.  A  black  eschar  forms,  which  becomes  slowlj^  separated 
from  the  subjacent  tissues,  after  which  healing  takes  place  by  granu- 
lation. The  fourth  degree,  sometimes  subdivided  into  three  groups, 
so  that  the  total  number  of  degrees  is  six,  contains  all  cases  where 
the  lesions  are  more  than  simple  destruction  of  the  skin,  up  to  the 
complete  charring  of  a  limb  or  the  body. 

Pain  is  generally  slight  and  temporary  in  first  degree  burns;  it  is 
severe  in  those  of  the  second  degree,  especially  if  the  epidermic  cover 
of  blisters  has  been  ruptured  and  the  cutaneous  nerve  endings  of  the 
skin  are  bared.  In  the  third  and  fourth  degrees  there  is  little  or  no 
pain,  because  the  nerve  endings,  wliich  are  irritated  in  first  and  sec- 
ond degree  burns,  are  here  actually  destroyed.  But  around  third  and 
fourth  degree  burns  there  is  alwaj's  a  zone  of  second  and  first  degree 
lesions,  wliich  cause  intense  pain.  In  case  of  extensive  second  degree 
burns,  the  suffering  may  be  so  agonizing  that  the  patients  truly  die 
of  nervous  exhaustion  caused  by  pain. 

In  extensive  burns,  there  are  severe  general  symptoms  due  to 
7-eso!-))tion  of  toxins  from  the  charred  parts.  In  some  cases  the 
temperatuie  is  subnormal,  the  skin  becomes  pale  and  cold,  the  pulse 
is  «n]all  and  rapid  and  the  patient  dies  in  a  few  days  in  a  state  of 
collapse.  In  other  cases  there  is  high  temperature,  delirium,  diarrhea 
and  coma.  At  autopsy,  intestinal  nicenitions  aj-e  found,  particularly 
in  the  duodenum,  also  ecchymoses  and  tliromhoses  in  all  the  organs, 
parenchymatous  nephritis,  etc. 

If  the  })atient  survives,  burns  of  the  first  and  second  degree  he;il 
sim])ly,  Avithont  leaving  any  scar,  provided  no  infection  has  sup'^r- 
rcncd.  In  the  third  degree,  liealing  takes  i)lace  by  granulation  after 
shedding  of  the  eschar;  the  process  of  cicatrization  is  slow,  and  the 

217 


scars  are  hypertrophic,  unsightly,  adherent  to  the  deeper  tissues,  and 
have  a  marked  tendency  to  become  retracted.  This  latter  character 
often  proves  very  troublesome,  as  a  joint  may  be  immobilized  in 
faulty  position,  and  a  limb  made  useless,  not  to  speak  of  the  resulting 
deformity. 

But  burns  have  an  unfortunate  tendency  to  become  septic,  and 
when  infection  occurs,  it  greatly  complicates  matters.  Suppuration 
in  extensive  burns  may  cause  progressive  exhaustion,  and  death  from 
amyloid  degeneration;  at  best,  it  markedly  retards  recovery  and 
makes  the  scar  still  uglier. 

This  gives  us  the  general  indications  for  treatment:  allay  the 
pain,  and  prevent  infection.  As  pain  is  due  to  a  great  extent  to 
exposure  of  nerve  endings  to  air  contact,  therapeutic  deductions  are 
obvious :  disinfect  the  burned  part,  under  general  anesthesia,  if  neces- 
sary, and  apply  a  sterile  dressing  (no  antiseptics,  for  fear  of  possible 
absorption).  The  same  effect  is  obtained  by  keeping  the  patient, 
or  at  least  the  burned  limb,  in  a  sterile  hath  evenly  maintained  at 
body  temperature:  this  is  the  handiest  way  of  treating  extensive 
burns,  and  the  one  that  most  relieves  the  patient.  In  second  degree 
burns  care  must  be  taken  not  to  break  the  epidermic  cover  of  the 
blister;  the  latter,  if  large,  is  evacuated  by  a  puncture  made  in  a 
point  of  the  periphery  with  a  fine  sterilized  needle.  In  burns  of  the 
first  degree,  where  the  skin  is  unbroken,  we  need  not  be  so  particular 
about  the  means  employed :  flour,  talcum  powder,  bismuth  subnitrate, 
oil,  are  all  good.  A  mixture  of  equal  parts  of  lime  water  and  olive 
oil  (Carron  oil)  has  a  somewhat  surfeited  repute  in  burns. 

When  repair  has  progressed  to  the  point  when  the  dead  has  been 
demarcated  from  the  quick,  various  operations  may  be  needed  to 
regularize  the  parts.  Probably  no  condition  requires  skin  grafting 
as  frequentl}^  and  extensively  as  burns.  Charred  and  necrosed  bones 
(second  and  fifth  fingers  in  Fig.  136)  must  be  exarticulated ;  likewise 
must  be  parts  so  mutilated  that  they  are  no  longer  capable  of  function. 

Of  course,  during  all  the  period  of  repair,  the  general  strength 
of  the  body  must  be  promoted  by  diet  and  tonics.  In  the  beginning, 
caffeine,  digitalis,  camphor  oil  may  be  called  to  sustain  a  faltering 
heart,  and  saline  infusions  to  restore  tone  to  a  weakened  vascular 
system.  Morphia  must  be  used  only  when  absolutely  necessary,  as  it 
inhibits  the  working  of  the  kidney,  which  is  essential  to  recovery  and, 
on  the  contrary,  must  be  stimulated  by  diuretics. 

(See  again  the  treatment  of  granulating  wounds,  Fig.  55  and 


218 


l!ockciilu'iim>r,  Atlas. 


Tab.  CIX. 


Fig.  137.    Congelatio  erythematosa  —  bullosa. 


Hdini.in  Comp.iny,  N'ew-\'ork. 


Tab.  ex. 


Bockenheimer,  Atlas. 


Fig.  138.     Combustio  (X-Rays). 


Rebman  Company,  New- York. 


page  75;  see  also  Figs.  58  .iiid  59,  keloids,  as  soars  of  burns  have 
a  marked  tendeucy  to  keloidal  liypcrtidpliy.) 

Chemical  burns  often  require  chemical  neutralization :  acids 
(vinegar,  lemon  juice)  for  alkalies;  alkalies  (baking  soda,  soap)  for 
acids;  but  this  neutralization  is  of  no  value  unless  applied  a  very 
short  time  after  the  caustic  substance. 

Heatstroke,  sunstroke,  lightning  stroke  ami  electrocution  are 
other  effects  of  heat,  but  cannot  be  considered  here,  as  their  treat- 
ment is  purely  non-surgical,  and  they  raise  too  complicated  physio- 
logical questions. 


Fig.  138  shows  an  X-ray  burn  which  followed  a  long  exposure 
made  for  a  swelling  of  the  thigh.  The  skin  became  red,  then  white, 
and  finally  ulcerated  in  several  places.  The  brown  coloration  indi- 
cates healing  of  the  less  affected  parts.  The  lalcers  healed  after  the 
application  of  simple  dusting  powder. 

X-ray  dermatitis  was  frequent  and  severe  in  the  early  days  of 
radiologj',  when  the  potentiality  for  harm  of  the  rays  had  not  been 
recognized  and  workers  did  not  protect  themselves.  Several  enthusi- 
astic pioneers,  after  suffering  for  years  from  a  chronic  dermatitis, 
with  dry,  cracked  and  fissured  skin,  brittleness  and  falling  of  the 
nails,  sometimes  necrosis,  have  seen  X-rai/  carcinoma  develop  in  their 
hands,  and  despite  multiple  and  mutilating  operations,  have  lost  their 
upper  limbs  and  finally  succumbed  after  years  of  untold  suffering. 

To-day  we  know  how  to  limit  the  action  of  the  X-rays  to  the  part 
we  want  to  treat :  the  use  of  lead  glass  in  X-ray  tubes  is  a  sufficient 
protection  for  the  workers,  and  we  know  how  to  administer  X-rays 
in  graduated  doses.  There  are  several  means  of  measuring  the  quan- 
tity given,  and  to  each  disease  seems  to  correspond  a  determined  dose, 
sufflcient  and  necessary  for  a  cure.  This  is  the  principle  of  the  single 
dose  method  (Mackee),  which  in  some  conditions  (favus,  keloids  and 
particularly  rodent  ulcer,  see  page  3)  seems  to  give  better  results 
than  the  older,  empirical,  fractional  method. 

There  is  no  individual  susceptibility  to  the  X-ray;  that  is,  a  given 
dose,  measui'ed  in  Holzknecht  units,  will  produce  the  same  therapeutic 
effect,  or  the  same  burn,  in  different  individuals,  if  applied  to  the 
same  region.  The  only  variations  are  those  due  to  age.  A  slight 
reaction  is  often  therapeutically  sought  in  many  dermatoses. 

The  case  shown  in  Fig.  138  is  interesting  because  the  X-rays, 
which  were  ajiplied  to  a  peripheral  sarcoma  of  the  femur,  not  only 

219 


caused  no  improvement,  but  aggravated  the  tumor.  This  demon- 
strates the  inefficiency  of  treatment  of  some  malignant  tumors  by  the 
X-rays,  and,  as  operative  interference  is  postponed,  more  extensive 
removal  becomes  necessary  later  on  (see  page  30).  In  this  case 
X-ray  examination  showed  the  presence  of  sarcomatous  masses  in 
the  soft  parts,  necessitating  high  amputation  through  the  thigh. 


Fig.  137  shows  a  case  of  frostbite  of  the  first  and  second  degrees 
in  a  workman  who  had  had  repeated  milder  attacks  in  the  winter, 
after  exposure  of  his  hands  to  cold  water  during  his  work.  The 
hands  were  permanently  blue,  and  in  the  winter  painful  chilblains 
developed  on  the  fingers,  especially  on  the  extensor  surface.  He 
finally  developed  frostbite  of  the  second  degree,  which  is  shown  by 
the  whiteness  of  the  ends  of  the  fingers,  and  other  changes  in  the 
fourth  finger.  The  skin  over  the  first  joint  of  the  fourth  finger  is 
blue,  and  a  large  blister  containing  yellow  lymph  has  developed  on 
the  extensor  surface  of  the  last  joint. 

Cold  as  well  as  heat  may  destroy  tissues.  Here  again  the  effects 
depend  on  the  degree  of  cold,  the  duration  of  its  action  and  the  con- 
dition of  the  patient.  Dry  cold  is  better  borne  than  moist  cold.  Cer- 
tain individuals  are  especially  liable  to  the  effects  of  cold — persons 
in  a  state  of  alcoholic  intoxication,  anemic  individuals,  children  and 
old  people,  cooks  and  others  who  are  exposed  to  rapid  changes  of 
temperature.  Frostbite  may  be  caused  by  the  action  of  snow,  ice, 
liquid  air  or  carbon  dioxide  snow.  The  latter,  which  in  the  past  few 
years  has  become  a  valuable  therapeutic  agent  in  dermatological 
practice  (see  treatment  of  neevi,  page  104),  must  be  handled  cai'efully. 

Chilblain  {or  pernio)  maybe  regarded  as  a  chronic  form  of  frost- 
hite,  affecting  the  fingers,  toes  and  ears.  It  is  especially  common  in 
chlorotic  subjects  and  causes  swelling  and  cyanosis  of  the  skin  with 
numerous  bluish-red  nodules.  These  often  cause  unbearable  itching 
and  burning  sensations,  and,  when  scratched,  give  rise  to  intractable 
ulcers. 

There  are  several  degrees  of  acute  congelation  of  tissues,  just 
as  there  are  degrees  in  burns.  Those  parts  of  the  body  that  are  most 
exposed  and  where  the  circulation  is  slackest  are  most  frequently 
affected:  namely,  the  ears,  nose  and  toes. 

In  the  first  degree  of  frostbite  there  is  redness  of  the  skin  from 
hyperemia  (erythematous  congelation).  This  is  usually  followed  in 
a  short  time  by  the  development  of  a  blister.    The  redness  increases 

320 


l'(K'k(iiliciinci',  Alias. 


Tab.  f.XI. 


Mg.  IjU,    A\al  iierl'tiraiit  ilu  pied         Ganyraciia  Raynaud. 


Rcbmaii  Company,  Nc\v-Yoil<. 


Bockenlieinier,  Atlas. 


Tab.  CXII. 


Fig.  140.    Gangraena  diabetica  —  Arteriosklerosis. 


Robraari  Coiii|)3iiy,  Ncw-Yoik. 


wln'ii  the  jiatieiit  coines  into  a  warm  room,  or  takes  alcoliolic  drinks. 
It  is  accompanied  by  burninf?  and  itcliinfj:  pains,  which  may  continue 
for  a  long  time.    But  recovery  is  the  rule. 

A  longer  exposure,  or  exjoosure  to  more  severe  cold,  causes  venous 
stasis,  edema,  and  blister  formation.  In  this  second  degree,  as  in  the 
second  degree  of  burns,  pain  is  more  severe.  Tiie  skin  becomes  blue 
or  white,  cold  and  insensitive  to  the  touch,  and  is  often  covered  with 
numerous  blisters,  with  l)hiish-black  contents;  after  rupture  of  these 
blisters  the  exposed  corium  is  dark  in  color  and  very  painful.  Infec- 
tion is  liable  to  occur,  causing  extensive  ulceration  with  little  ten- 
dency to  heal,  and  leading  to  cicatricial  contraction. 

In  frostbite  of  the  third  degree,  in  the  same  way  as  in  third  degree 
burns,  there  is  sloughing  of  the  skin  and  necrosis  of  the  deeper 
tissues,  due  to  thrombosis  of  the  vessels.  The  skin  is  at  first  bluish- 
black,  cold  and  insensitive,  later  on  quite  black.  Separation  of  the 
frozen  tissues  may  take  place  either  by  dry  or  moist  gangrene.  The 
zone  of  demarcation  has  often  a  putrid  character.  Progressive 
phlegmonous  inflannnation  may  sjjread  from  the  borders  of  the  frozen 
area,  and  may  lead  to  general  infection.  Along  with  frostbite  of  the 
third  degree  the  neighboring  parts  are  affected  in  the  tirst  and  sec- 
ond degrees,  and  other  parts  are  ulcerated;  so  that  the  clinical  pic- 
ture is  variegated.  The  dead  parts,  after  some  months,  are  east  off 
spontaneously.  The  nails  soon  fall  off  in  frostbite  of  the  hand.  In 
frostbite  of  the  third  degree,  parts  which  at  first  showed  signs  of 
the  second  degree  only,  may  afterward  become  gangrenous. 

Healing  eventually  takes  place  by  production  of  very  unsightly 
hypertrophic  scars,  which  may  cause  retractions.  Contractures  may 
also  be  caused  by  paralysis  of  nerves,  or  by  waxy  degeneration  of 
muscle  fibres.  Frostbite  is  said  to  cause  changes  in  the  blood-vessels 
which  may  lead  to  secondary  gangrene. 

The  general  condition  of  the  patient  is  little  impaired  in  acute 
local  frostbite  of  circumscribed  re.gions.  The  period  of  healing  varies 
according  to  the  degree  of  the  frostbite,  but  is  usually  longer  than  in 
burns  and  after  effects  are  more  sevei-e. 

General  frostbite  is  observed  in  very  cold  winters,  in  persons  lost 
in  the  snow,  and  in  Arctic  ex])lorei-s.  An  invincible  somnolence  is  a 
premonitory  symptom.  If  the  sufferer  is  allowed  to  stop  and  sleep, 
he  certainly  will  freeze  to  death,  bnly  early  attempts  at  resuscitation 
have  any  (li.nnc  of  success.  Patients  must  be  very  gradually 
warmed;  jilaced  at  first  in  a  cold  room  and  rul)])ed  with  snow,  then 
with  ice  water,  then,  in  the  course  of  several  hours,  the  temperature 

221 


is  very  slowly  raised.  If  breathing  has  stopped,  artificial  respiration 
must  be  resorted  to. 

Chilblains  may  be  treated  by  hot  air  apparatus  or  sandbaths, 
together  with  the  general  treatment  of  anemia  with  iron  and  arsenic. 
The  irritation  may  be  relieved  by  painting  with  tincture  of  iodine, 
balsam  of  Peru.  Ulcers  are  best  treated  with  mild  antiseptic  dress- 
ings and  bland  ointments.  Eecurrence  can  be  limited  by  prophylactic 
measures,  avoidance  of  exposure  to  cold  and  wearing  woollen  gar- 
ments. 

In  acute  local  frostbite  the  parts  must  be  warmed  gradually — by 
rubbing  with  snow  or  cold  applications.  Early  treatment  in  this  way 
may  restore  the  frozen  skin.  In  frostbite  of  the  second  degree  large 
blisters  should  be  opened  and  broken  epidermis  pared  oft".  Ulcers 
should  be  treated  with  strict  asepsis,  and  dressed  with  sterile  gauze 
or  ointment.  The  extremities  should  be  suspended  on  splints,  all 
pressure  being  carefully  avoided. 

In  cases  with  moist  gangrene  and  putrefactive  phlegmonous  in- 
flammation, early  amputation  is  often  necessary  to  prevent  general 
infection.  In  dry  gangrene,  amputation  may  be  deferred  till  a  zone 
of  demarcation  has  formed.  Plastic  operations  are  often  required 
after  spontaneous  separation  of  gangrenous  parts  of  the  fingers  or 
toes.  Morphia  may  be  necessary  for  the  severe  pain  in  the  early 
stages  o:f  frostbite  and  has  not  the  drawbacks  it  has  in  burns. 


Fig.  141  shows  a  case  of  gouty  arthritis  of  the  metacarpo- 
phalangeal joint  of  the  second  finger,  in  a  predisposed  subject,  who 
had  already  had  several  previous  attacks.  The  whole  joint  is  swollen 
and  very  painful  to  touch  and  on  movement.  Tophi  are  present  on 
the  other  metacarpo-phalahgeal  joints  and  on  the  interphalangeal 
joints  of  the  second  to  the  fifth  fingers.  The  skin  over  the  tophi  is 
white  from  pressure. 

Gout  is  a  disorder  of  metabolism  occurring  in  middle-aged  men, 
often  with  a  hereditary  predisposition,  who  indulge  in  high  living  and 
take  too  little  exercise. 

Sodium  urate  is  imperfectly  eliminated  and  deposits  are  formed 
in  various  places,  especially  the  articular  cartilages,  but  also  in  the 
synovial  membranes,  tendons,  subcutaneous  and  periarticular  tissue, 
bursEe,  bronchi,  intestinal  mucosa  and  kidneys. 

An  acute  attack  of  gout  is  caused  by  deposits  of  sodium  urate 
in  a  joint,  usually  the  metatarso-phalangeal  joint  of  the  gi-eat  toe 

233 


Bockeiiliciincr,  Alias. 


Tab.  CXIII 


Fiff,  141.    Arlliritis  urica. 


Ivi'limmi  Caiup.iiiy,  New-\'oik. 


{Podagra).  The  syinptoins  are  grent  pain  in  the  affected  joint,  slight 
rise  of  temperature  and  a  certain  amount  of  constitutional  disturb- 
ance (gastric  pain,  nervous  plieuomeua,  rheumatic  pains,  etc.).  The 
first  attack  is  sometimes  excited  by  an  injury  to  the  foot.  The  region 
of  the  joint  is  swollen  and  edematous,  and  the  skin  shows  erysipela- 
tous reddening  and  phlegmonous  infiltration.  The  slightest  touch  or 
movement  causes  intense  pain.  There  is  a  slight  effusion  in  the 
joint.  After  some  hours  the  pain  subsides,  but  it  generally  recurs 
on  the  second  night ;  and  so  on  for  about  two  weeks,  till  the  attacks 
gradually  become  less  painful  and  finally  disappear.  A  slight  swell- 
ing of  the  affected  joint  remains.  Later  on  fresh  attacks  may  occur, 
often  after  many  years.  During  the  attacks  there  is  always  a  heavy 
sediment  in  the  urine.  Repeated  attacks  may  give  rise  to  a  per- 
manent nodular  swelling  of  the  joint,  and  slight  trauma  may  bring 
on  another  acute  attack  (e.g.  vigorous  shake-hand  on  gouty  fingers, 
stubbing  of  the  toes). 

Chronic  gout,  which  is  rarely  primary  and  generally  results 
from  the  acute  form,  is  observed  also  among  the  poorer  classes.  It 
often  affects  articulations,  but  is  less  painful.  The  frequency  with 
which  the  metatarso-phalangeal  joint  is  attacked  is  perhaps  due  to 
bad  circulation  of  the  blood,  owing  to  its  peripheral  position.  (This 
joint  is  also  affected  by  arthritis  deformans  in  old  people).  Large 
deposits  of  sodium  urate  give  rise  to  gouty  nodules  or  tophi,  which 
occur  in  the  joints  of  the  fingers,  hand,  foot  and  elbow.  They  also 
occur  in  the  cartilages  of  the  ear,  nose  and  eyelids  in  the  form  of 
small,  yellowish  nodules,  which  become  hard  and  painful.  In  ad- 
vanced cases  these  nodules  may  be  found  in  all  articular  and  peri- 
articular structures,  tendon-sheaths,  cartilages  of  the  ribs,  and  in 
other  tissues. 

Chronic  gout  is  very  liable  to  acute  flare-ups,  especially  after 
indiscretions  in  diet.  Tomatoes  are  believed  to  have  a  very  bad  influ- 
ence and  Johnson  has  desci-ibed  what  he  calls  the  ininafo  joint.  There 
may  be  some  slight  exaggeration  in  this. 

Microscopical  examination  of  gouty  deposits  shows  the  ]")resence 
of  sodium  urate  crystals.  These  act  as  foreign  bodies  and  cause 
pain  and  pressure  necrosis.  The  cartilages  are  eroded;  subluxation 
and  ankylosis  are  frequent.  Suppurative  arthritis  is  always  due  to  a 
mixed  infection  and  a  serious  complication. 

Although  joints  are  chiefly  affected,  gouty  deposits  in  other  organs 
may  give  rise  to  the  most  diverse  symptoms :  |);uii  in  the  heel,  sciatica, 
lumbago,  asthma,  bronchitis,  nei)lirilis,  iritis,  emiihysoma,  etc. 

2-2  r, 


Chronic  interstitial  nephritis  and  calculus  are  the  two  main  com- 
plications in  gout  of  long  standing. 

Diagnosis 

Gouty  arthritis  is  most  often  confounded  with  chronic  rheuma- 
tism, but  in  the  latter  the  skiu  over  the  joints  is  unchanged.  In 
purulent  arthritis  there  is  high  temperature  and  rigors,  while  the 
temperature  in  gout  does  not  exceed  100°  provided  no  suppuration 
is  present.  The  localization  of  gouty  arthritis  to  small  joints  of  the 
hands  and  feet  is  a  good  diagiiostic  sign;  but  this  is  not  constant. 
Enchondroma  of  the  fingers  (Fig.  50)  differs  from  gouty  deposits 
by  the  absence  of  pain  and  its  size. 

Gout  of  other  organs  must  be  diagnosed  by  the  history  of  the 
ease.  Large  deposits  of  sodium  urate  can  be  seen  by  X-ray  exam- 
ination; e.g.  in  bursse. 

Treatment 

Treatment  of  uncomplicated  gout  is  purely  internal.  Prophylaxis 
consists  mainly  in  hygienic  and  dietetic  prescriptions,  care  being  par- 
ticularly paid  to  the  purin  contents  of  food.  During  acute  attacks, 
colchicum  and  rest;  in  the  interval,  hot  air  hyperemia  and  mineral 
water  "cures"  are  the  main  therapeutic  elements. 

Surgery  intervenes  in  gout  only  in  case  of  complications,  such  as 
suppurative  arthritis,  or  of  sequelae,  such  as  stone  of  the  kidney. 


334 


MALFORMATIONS 

Figs.  142-150 


Bockenheimer,  Atlas. 


Tab.  CXIV. 


Fig.  142.    Encephalocele  occipitalis  —  Raciiiscliisis. 


Rebman  Company,  New- York. 


MALFORMATIONS 

Figs.  142  ti)  149,  inclusive,  leiiresent  congenital  malformations. 

Tlieso  nrc  arcouiilcd  for  l)y  enil)ryolo.<iV. 

Slight  developmental  disturl)an('e.s  are  called  (niouiaUes:  greater 
deformities,  malformations. . 

There  are  primary  malformations  which  affect  the  embryo  early 
in  its  development,  and  secondary  malformations,  or  arrests  of  rle- 
velopment,  in  which  an  influence  acting  later  in  intra-uterine  life 
modifies  the  gi'owth  of  a  part  already  formed.  The  earlier  the  cause 
begins  to  act,  the  greater  the  malformation.  The  causes  which  lead 
to  malformation  may  be  intrinsic,  that  is,  lie  in  the  embryo  itself,  or 
of  external  origin.  Experimental  observations  on  animals  have  shown 
that  malformations  may  be  caused  by  injury.  In  the  lower  extremi- 
ties malformations  may  be  caused  by  pressure  or  by  abnormal 
positions  of  the  fetus  in  the  uterus  (various  forms  of  talipes — 
pes  vai'us,  pes  valgus,  pes  calcaneus).  Pressure  on  the  fetus  may  be 
caused  by  a  uterine  tumor  or  by  deficiency  in  the  liquor  anmii.  and 
signs  of  such  pressure  can  often  be  seen  after  birth  of  the  child.  Many 
malformations  are  due  to  anomalies  in  the  membranes ;  e.g.  amniotic 
adhesions,  which  may  prevent  the  union  of  parts  which  should  nor- 
mally become  united  (branchial  clefts)  or  may  cause  duplication  of 
parts,  or  partial  or  complete  separation  (amniotic  amputations, 
Fig.  149,  aberrant  glands). 


Figs.  142,  143,  nnd  144  rejiresent  malformations  due  to  imperfect 
closure  of  the  cerebrospinal  canal.  In  the  spine,  there  result  dif- 
ferent degrees  of  spina  bifida,  from  meningocele  and  spina  bifida 
occidta  to  rachiscliisis  (Fig.  142).  In  the  skull,  there  is  formed  an 
encephalocele  (Fig.  142).  which  is  nothing  but  a  cranial  spina  bifida. 

Encepfialocele  occurs  in  the  nasal  region  (s;sTicipital  encephalo- 
cele, subdivided  into  naso-ethmoidal,  naso-frontal  and  naso-orbital 
varieties)  and  in  the  occipital  region  (occipital  encephalocele,  distin- 
guished as  superior  and  inferior  according  to  its  situation  above  or 
below  the  occijiital  ]irotuberance).  ETicejihalocele  is  rare  (about  1 
case  in  5000  births). 

In  extensive  cases  there  may  be  acrania  or  anencephalus.  while 

227 


in  slighter  degrees  there  is  only  a  defect  in  the  bone  and  dura  mater. 
Owing  to  the  defect  in  the  dura  mater  there  may  be  prolapse  of  the 
brain  through  the  bone  {encephalocele  proper);  generally  there  is  a 
hernial  protrusion  of  one  of  the  ventricles  (hydroencephalocele) .  The 
existence  of  a  true  congenital  meningocele  in  which  the  dura  is  intact, 
and  there  is  only  protrusion  of  the  membranes  through  the  gap  in  the 
bone,  rtiust  be  regarded  as  doubtful.  Bockenheimer's  observations 
on  myelocele  (Fig.  144)  have  also  shown  that  the  inner  covering  of 
the  protrusion,  which  is  said  to  be  dura,  often  consists  of  connective 
tissue  only,  and  that  the  inner  wall  is  often  formed  of  ciliated  colum- 
nar epithelium,  and,  therefore,  represents  the  degenerated  ventricle  of 
the  brain.  Hence  the  so-called  meningocele  is  a  true  encephalocele 
(or myelocystocele).  Again,  so-called encephalomeningocele  hasbeen 
shown  to  be  not  a  true  meningocele,  but  a  cystic  formation  which  has 
become  gradually  cut  off  from  a  primary  hernia  cerebri  or  encephalo- 
cele. 

As  the  subdivision  of  the  different  forms  into  meningoceles,  en- 
cephaloceles,  encephalomeningoceles,  encephalocystoceles  and  ence- 
phalocysto-meningoceles  depends  on  pathological  anatomy,  and  can- 
not be  made  clinically,  it  is  sufficient  for  all  practical  purposes  to  use 
the  term  encephalocele  for  all  hernial  protrusions  through  the  skull. 

Syncipital  encephaloceles  generally  have  a  wide  base  while  occipi- 
tal eneephaloceles  are  pedunculated  (Fig.  142)  and  may  attain  a 
large  size  (as  large  as  the  child's  head)  ;  the  skin  at  the  base  of  the 
tumor  is  thickened  and  covered  with  radially  arranged  hair.  The 
tumor  may  be  covered  with  normal  skin,  but  more  commonly  most 
of  the  surface  resembles  fresh  scar  tissue ;  or,  when  ulceration  is  pres- 
ent, it  resembles  the  mucous  membrane  of  the  intestine.  Vascular 
anomalies,  telangiectases  and  angiomata,  are  often  present. 

The  tumor  is  diminished  by  pressure,  and  can  be  completely  emp- 
tied in  cases  when  it  apparently  contains  only  fluid.  After  the  tumor 
has  been  emptied  by  pressure  the  hole  in  the  skull  can  be  felt,  situated 
symmetrically  in  the  middle  line.  It  is  generally  small  and  circular, 
and  can  sometimes  be  shown  by  X-ray  examination.  As  the  tumor 
can  be  decreased  by  external  pressure,  so  is  it  increased  by  internal 
pressure;  e.g.  when  the  child  cries. 

In  some  cases  there  is  but  little  diminution  on  pressure.  Irregular 
partitions  can  then  be  felt  in  the  interior  of  the  sac.  Firm  pressure 
then  usually  causes  bulging  of  the  fontanelle,  or  sometimes  convul- 
sions. Cystic  encephaloceles  may  be  translucent.  In  other  cases 
there  may  be  pulsation.    Then  the  skull  is  usually  very  small  and  fiat- 

228 


lliickenlicimcr,  Atlas. 


Tab.  CXV. 


Fig.  143.    Myelocele   -    Pedes  var 


Rebnuin  Company,  New-York. 


Bockenheimer,  Atlas. 


Tab.  CXVI. 


Fig.  144.    Myelocystocele  -  Myxolipoma. 


Rebman  Company,  New-York. 


tened,  and  other  iiiaH'onnntions  are  present;  the  infants  are  weakly 
and  Lave  a  subnormal  teniporature. 

Spina  bifida  is  sli^Ltly  more  frequent  than  eneephalocele  (15  in 
10000  infants)  and  exists  in  several  deg-rees.  The  most  extreme  is 
rachischisis  (Fig.  142),  in  which  there  is  a  hu'k  of  closure  of  the 
bones,  soft  parts,  spinal  cord  and  membranes.  It  may  extend  for  the 
whole  length  of  the  spine  (total  posterior  rachischisis)  or  be  limited 
to  a  shorter  segment.  In  Fig.  142  it  extends  from  the  twelfth  dorsal 
to  the  third  lumbar  vertebra.  It  is  most  common  in  the  lumbo-sacral 
region,  because  in  this  region  the  medullary  groove  closes  last  to  form 
the  neural  canal.  Eachischisis  is  usually  associated  with  other  exten- 
sive malformations,  such  as  aueucephalus,  acrania,  absence  of  verte- 
bral bodies,  etc.  Three  typical  zones  can  be  distinguished  symmet- 
rically on  each  side  of  the  vertebral  column :  (] )  a  circular,  peripheral 
zone  of  ihichened  skin,  often  covered  with  abundant  hair;  (2)  a  mid- 
dle zone  which  resembles  fresh  cutaneous  scar  tissue,  or  the  serous 
coat  of  the  intestine,  and  hence  has  been  called  the  epithelio-serous 
zone;  a  central  zone  of  flabby  granulations  with  a  depression  at  the 
upper  and  lower  ends,  which  represents  the  open  and  exposed  spinal 
cord.  The  depressions  at  each  end  of  the  central  zone  lead  to  the 
ependymal  canal  of  the  spinal  cord.  Rachischisis  is  caused  by  a  very 
early  arrest  of  development  in  embryonic  life.  The  second  form 
{myelocele)  results  from  a  later  disturbance  and  is  limited  to  a  smaller 
extent  of  the  spine,  although  it  may  include  the  soft  parts,  bones  and 
spinal  cord;  this  forms  a  tumor-like  swelling.  The  third  form  {mye- 
locystocele) occurs  still  later  in  embrj'onic  life,  at  a  time  when  the 
spinal  cord  and  the  skin  have  already  closed  on  the  dorsal  surface  of 
the  embryo,  but  the  dura  mater  and  bone  have  not  yet  united.  The 
fourth  form  {meningocele)  only  occurs  in  the  lumbo-sacral  region 
where  the  spinal  cord  has  become  the  filum  terminate.  Spina  bifida 
occulta,  which  also  occurs  at  the  lower  extremity  of  the  vertebral 
column,  is  not  to  be  regarded  as  a  special  form,  but  as  a  meningocele. 

By  far  tlie  most  common  variety  is  myelocele  (Fig.  143),  which 
is  usually  situated  in  the  lumbo-sacral  region,  sometimes  in  the  cervi- 
cal or  thoracic.  It  forms  a  characteristic  swelling  with  a  broad  base, 
symmetrical  as  to  the  midline,  with  the  three  zones  already  described 
for  rachischisis,  viz. :  external  of  hairy  thickened  skin ;  middle,  epithe- 
lio-serous; central  on  the  apex  of  the  tumor,  red,  very  vascular  and 
covered  with  piis  a  few  days  after  birth.  This  third  zone  is  called 
vasculo-medullary  and  represents  the  remains  of  the  cleft  spinal  cord. 

229 


At  its  upper  and  lower  ends  are  depressions  througli  which  a  probe 
can  be  passed  into  the  ependymal  canal. 

In  myelocele  there  is  no  reductibility  on  pressure,  owing  to  the 
absence  of  communication  with  the  subarachnoid  space. 

In  myelocele  the  spinal  nerves  become  dragged  upon  by  the  in- 
creasing growth  and  motor  paralysis  of  the  lower  extremities,  blad- 
der and  rectum  (of  the  upper  extremities  in  high  myelocele)  results. 
The  common  occurrence  of  pes  varus  in  these  cases  (Fig.  143)  is  due 
to  the  myelocele  being  usually  situated  at  the  junction  of  the  lumbar 
A^ertebrge  with  the  sacrum  where  arise  the  nerves  supplying  the  an- 
terior and  posterior  tibial  muscles ;  viz.  fourth  and  fifth  lumbar,  first 
and  second  sacral  nerves.  Sensory  disorders  are  rare  in  myelocele, 
but  trophoneurotic  disorders  occur  in  the  form  of  extensive  eczema 
and  decubital  ulcers,  especially  on  the  feet ;  in  pes  varus  on  the  outer 
border  of  the  foot.  Other  malformations,  umbilical  hernia,  etc.,  are 
frequently  associated  with  myelocele. 

Myelocystocele  (Fig.  144)  is  caused  by  arrest  of  development  of 
the  vertebral  arches  and  the  dura  mater  only.  It  appears  in  the  third 
week  of  embryonic  life,  at  a  time  when  the  medullary  groove  has 
closed  to  form  the  neural  tube,  and  the  epiblast  has  grown  over  it. 
Hydrops  of  the  central  canal  causes  bulging  of  the  posterior  part  of 
the  spinal  cord  through  the  gap  in  the  vertebral  arches,  giving  rise  to 
a  tumor-like  swelling  of  the  spinal  cord  covered  by  the  soft  parts.  The 
substance  of  the  spinal  cord  soon  undergoes  degeneration  and  can 
only  be  identified  by  the  presence  of  ciliated  cylindrical  epithelium 
on  the  inner  surface  of  tire  cavity  (the  remains  of  the  ciliated  epithe- 
lium of  the  central  canal  of  the  spinal  cord).  In  the  exteimal  cover- 
ings of  myelocystocele  there  is  often  lipoma,  myxoma,  lipomyxoma 
(Fig.  144),  lymphangioma  or  teratoma.  The  tumor  has  a  wide  base 
and  is  covered  with  normal  skin,  which  is  thickened  at  the  base  of  the 
tumor.  Sometimes  small  depressions  caused  by  the  remains  of  amni- 
otic bands  are  present  in  the  skin  (Fig.  144).  The  tumor  is  of  soft 
consistency,  and  fluctuation  is  always  elicited.  The  fluid  contents  of 
the  tumor  can  he  completely  reduced  by  pressure,  as  there  is  direct 
communication  with  the  central  canal,  and  also  with  the  subarachnoid 
space.  By  pressing  on  the  tumor  the  transmission  of  fluid  pressure 
can  be  felt  at  the  f  ontanelle. 

Myelocystocele  is  often  combined  with  hydrocephalus.  Paralyses 
are  rare,  as  the  motor  nerves  are  not  displaced  by  the  malformation ; 
at  the  most  there  may  be  pes  varus  or  valgus  on  one  side,  due  to  the 
tumor  being  situated  unsymmetrically  more  to  one  side  of  the  midline 

230 


iiiid  thus  piilliiiii'  on  a  motor  nerve  I  Idwcvcr,  extensive  myoloey.sto- 
(•(•le  (if  tlie  Innilio-siicnil  reition  ni;iy  ciuse  ii;ii;ilysis  of  the  bladder  and 
rccliiMi.  'I'r(i|iliuiici:rntir  (li^(ll•(lel•s  are  coniinnii.  Sometimes  paraly- 
sis Dci'urs  at  a  later  a^e,  the  tumor  gradually  increasing  in  size  and 
dragging  on  tlie  spinal  cord  and  nerves.  Defective  bone  formation  is 
often  associated  with  iiiyolocystoccle — absence  of  vertebral  bodies, 
unilateral  defects  in  the  vcilchral  laminae,  absence  of  ribs  or  patella, 
scoliosis,  olc. 

Meningocele  I'aii  (Hily  (iccur  in  places  where  the  >pinal  conl  is 
absent.  ]n  this  condition  there  is  a  defect  in  the  foi'uiation  of  the 
vertebra-  and  dura  mater,  so  that  the  pia  mater  protrudes  posteriorly, 
inclosing  the  filum  terminale.  In  this  way  a  pedunculated  swelling  is 
formed,  covered  by  )ion)iaI  skin,  which  may  attain  the  size  of  a  child's 
head  as  the  amount  of  cerebro-spinal  fluid  in  the  sac  increases.  Pa- 
ralysis only  occurs  when  the  meningocele  is  large,  and  generally  is  of 
limited  extent.  There  is  sometimes  an  abundant  growth  of  hair  ou 
the  prominent  part  of  the  swelling.  Fluctuation  is  always  present, 
but  there  is  only  slight  diminution  on  pressure.  The  space  in  the 
bone  is  generally  smaller  than  in  myelocele.  Meningocele  occurs  most 
often  in  the  sacral  region. 

Spina  Bifida  Occulta  is  a  form  of  meningocele  which  becomes 
ru])tured  and  undergoes  si^ontaneous  healing  under  the  skin.  The 
pressure  of  the  cicatrix  may  cause  disturbances  whfcli  are  not  noticed 
till  the  child  grows  older. 

Diagnosis  and  prognosis 

SjTicipita]  ence^jhalocele  may  be  mistaken  for  dermoid  (see  Fig, 
48)  or  lipoma.  The  diagnosis  depends  on  the  presence  of  a  gap  in  the 
bone,  diminution  of  the  tumor  on  pressure  and  the  presence  of  other 
deformities.     (See  page  64). 

Occipital  encephalocele  may  be  mistaken  for  ccpliaJhoiuitnnia, 
which  sometimes  occurs  ou  the  occipital  bone,  especially  as  the  base 
of  a  cephalhematoma  may  be  surrounded  by  a  hard  ring  due  to  the 
raised  periosteum.  Cephalhematoma  is  not  diminished  by  pressure. 
However,  diminution  by  pressure  may  be  absent  in  encephalocele  if 
the  gap  in  the  bone  is  occluded.  In  doubtful  cases  an  opei'atioh  will 
settle  the  diagnosis. 

Encephaloceles  must  be  distinguished  from  acquired  protrusions 
through  a  loss  of  substance  of  the  skull.  The  prognosis  is  generally- 
unfavorable,  but  is  better  in  cases  where  the  tumor  can  be  comjiletelv 
emptied  of  fluid  by  pressure,  and  when  no  brain  substance  can  be  felt 

231 


in  the  sac  after  evacuation  of  the  fluid.  Cases  of  occipital  encephalo- 
cele  with  a  large  gap  in  the  bone,  often  extending  to  the  vertebras  of 
the  neck,  and  protrusion  of  both  occipital  lobes  and  the  whole  of  the 
cerebellum,  are  soon  fatal.  Other  cases  have  a  surgical  interest  be- 
cause of  possible  operative  interference. 

That  a  tumor  implanted  in  the  midline  in  the  lumbar  region  (or 
more  rarely  in  other  parts  of  the  spine)  is  a  spina  bifida,  is  generally 
not  difficult  to  recognize :  the  nervous  disturbances,  motor,  sensory 
and  trophic,  the' paralysis  of  the  bladder  and  rectum,  the  varus  club- 
foot, all  point  to  a  spinal  cord  origin.  Communication  with  the  cere- 
bro-spinal  canal,  as  evidenced  by  reductibility  and  increase  of  pres- 
sure noticeable  at  the  fontanelles  is  pathognomonic,  but  does  not  exist 
in  all  forms.  Lipomata,  lymphangiomata,  teratoviata,  dermoids  are 
not  modified  by  pressure.  The  possible  coexistence  of  spina  bifida 
and  lipoma  (Fig.  144)  must  be  borne  in  mind.  Some  cases  of  very 
vascular  myelocele  might  be  mistaken  for  cavernoma  (compare  the 
objective  aspect  in  Figs.  75,  142  and  143),  but  the  latter  is  not  accom- 
panied by  any  nervous  disturbances. 

To  differentiate  clinically  from  one  another  the  several  varie- 
ties of  spina  bifida,  we  have  at  our  disposal  two  great  signs  which 
also  have  a  prognostic  significance.  The  absence  of  normal  skin  on 
the  tumor  and  of  diminution  on  pressure  characterizes  the  latter  as  a 
myelocele  or  rachischisis  (there  being  between  these  two  types  only 
a  difference  in  extent) ;  that  is,  we  have  to  deal  with  a  very  early 
trouble  in  the  evolution  of  the  cerebro-spinal  axis  itself;  tlie  cord  is 
malformed;  no  operative  cure  is  possible  and  death  will  result  in 
a  few  days  from  septic  meningitis,  because  the  meninges  are  widely 
open. 

On  the  other  hand  a  tumor  covered  ivith  normal  skin  and 
reducible  on  pressure,  announces  a  myelocystocele  or  meningocele, 
that  is,  a  malformation  due  to  a  much  later  trouble  in  the  evolution, 
with  a  spinal  cord  well  formed  except  for  the  functionless,  degener- 
ated part  contained  in  the  sac,  in  case  of  myelocystocele,  or  even  alto- 
gether normal,  in  ease  of  meningocele.  No  meningitis  is  to  be  feared, 
and  operative  correction  is  possible. 

To  sum  up,  the  prognosis  is  very  bad  in  myelocele,  when  the 
lesions  are  inoperable,  and  the  associated  malformations  often  of  the 
gravest  character;  it  is  not  unfavorable  in  myelocystocele,  provided 
other  malformations  are  absent  and  the  infant  has  a  strong  constitu- 
iion;  it  is  generally  good  in  meningocele. 

The  possibility  of  spina  bifida  occulta  must  always  be  borne  in 

232 


iiiiiiil  ill  cases  ol'  ti'(i|ili(iii('miilic  dixirilcfs  in  tlic  lower  extremities, 
the  ]iresenoo  of  whicli  is  liani  In  acciniiil  \'ny.  An  X-ray  exiiiuiiiation 
of  the  spine  will  then  solve  the  prolilcm.  Such  an  examination  is  al- 
ways useful,  even  in  the  other  varieties,  to  siiow  tlie  extent  of  the 
bone  malformations. 

Treatment 

Tapping  and  injection  are  useless,  and  dangerous  in  all  these  mal- 
formations of  the  nervous  system.  However,  tappliifi  is  tlie  only  pal- 
liative measure  applicable  in  myelocele  where  a  radical  operation  is 
impossible,  as  removing  the  cystic  sac  would  necessitate  dividing  the 
spinal  cord,  which  would  unite  with  the  scar.  On  the  other  hand, 
reduction  of  the  vasculo-medullary  zoiu>  would  simply  hasten  deatli 
by  se])tic  meningitis. 

But  in  eneephalocele,  myelocystocele  and  meningocele,  a  radical 
operation  is  possible;  it  is  somewhat  similar  in  principle  to  that  for 
hernia.  The  sac  is  exposed  by  a  free  incision,  dissected  down  to  the 
bone  and  opened;  the  contents  are  reduced  or  resected  according  to 
their  nature  and  importance,  the  sac  ligated  and  excised,  and  the  de- 
fect in  the  posterior  wall  repaired.  The  gap  in  the  bone  may  be 
bridged  over  by  suturing  the  periosteum  over  it,  by  a  pedunculated 
bone  flap,  a  bone  transplantation,  or  a  celluloid  or  silver  plate. 

In  case  of  eneephalocele,  where  brain  substance  is  found  in  the  sac, 
radical  operation  is  feasil)le  only  when  said  brain  substance  can  be' 
reduced  through  the  gap  in  the  bone  without  producing  cerebral  pres- 
sure symptoms.  Removal  of  portions  of  brain  still  possessed  of  func- 
tion may  cause  dangerous  disturbances,  but  a  degenerated  dropsical 
protrusion  may  be  removed  without  danger.  Cases  in  which  there  is 
a  large  defect  in  the  skull  and  cervical  vertebrae,  or  cases  combined 
with  other  extensive  malformations,  are  inoperable.  The  after-treat- 
ment is  complicated  by  the  escape  of  cerebro-spinal  fluid,  which  is  al- 
ways abundant,  even  after  the  most  careful  closure  of  the  bone  defect. 
The  dressings,  therefore,  require  changing  several  times  daily  to  ])re- 
vent  ascending  infection  of  the  wound. 

In  myelocystocele  the  sac  is  often  covered  by  a  fatty  tumor  which 
also  requires  removal.  Removal  of  the  sac  after  ligation  is  not  dan- 
gerous in  these  cases,  as  it  consists  only  of  functionless  degenerated 
spinal  cord.  Meningitis  sometimes  follows  these  operations,  but  most 
cases  recover  and  may  grow  up. 

In  meningocele,  conditions  are  best  and  the  operation  is  simple. 

In  spina  bifida  occnlta  with  disturbances  due  to  pressure  of  the 

233 


■cicatrix,  the  latter  may  be  excised  and  the  gap  in  the  bone  repaired. 
The  development  of  hydrocephalus,  which  may  occur  after  opera- 
tion on  all  forms,  is  an  unfavorable  sign. 

In  the  case  represented  in  Fig.  142,  the  encephalocele  could 
have  been  operated  on,  if  the  rachischisis  had  not  made  the  condi- 
tion of  the  child  hopeless. 

In  Fig.  143,  the  myelocele  was  accompanied  by  double  club" 

foot  {varus).    Death  occurred  soon  after  birth. 

In  the  case  shown  in  Fig.  144,  there  was  a  superficial  mass  of 
fatty  tissue,  while  underneath  was  a  cystic  tumor  which  could  almost 
loe  emptied  by  pressure.  There  were  no  motor  or  sensory  disorders 
present,  and  no  other  malformations.  The  X-rays  showed  a  small 
cleft  in  one  of  the  vertebral  arches  a  little  lateral  to  the  midline.  The 
superficial  fatty  tumor  was  removed  and  found  to  be  a  myxolipoma. 
The  myelocystocele  was  then  dissected  free  down  to  the  bone,  ligated 
and  removed.  The  gap  in  the  vertebra  was  closed  l)y  transplantation 
of  a  piece  of  the  iliac  crest.  Microscopic  examination  showed  the 
presence  of  cylindrical  epithelium  on  the  inner  wall  of  the  cyst,  thus 
confirming  the  diagnosis. 

A  few  words  must  be  added  about  the  varus  clubfoot,  shown  in 
Fig.  143.  Varus  clubfoot  may  be  congenital  or  acqtiired.  The  con- 
genital form  may  be  caused  by  arrested  development,  or  may  be  sec- 
ondary to  pressure  caused  by  amniotic  adhesions,  etc.  Congenital 
varus  is  common  in  connection  with  myelocele,  and  is  due  to  paralysis 
of  the  nerves,  as  already  explained. 

Acquired  varus  occurs  in  rickets,  and  as  the  result  of  poliomyelitis 
which  causes  paralysis  of  the  pronators  and  dorsal  flexors  of  the  foot. 
The  chief  effect  takes  place  at  the  midtarsal  joint  and  consists  in  su- 
pination, plantar  flexion,  internal  rotation  and  adduction.  Changes 
also  occur  in  the  astragalus  and  os  calcis,  especially  in  long-standing 
cases.  These  changes  can  be  seen  by  the  X-rays.  There  is  also  retrac- 
tion of  the  muscles,  tendons,  fascia  and  ligaments,  especially  short- 
ening of  the  tendo  Achillis  (talipes  equino-varus).  Pressure  ulcers 
may  develop  on  the  outer  border  of  the  foot. 

In  congenital  clubfoot  treatment  should  be  begun  as  early  as  pos- 
sible, by  repeated  manual  correction  (if  reduction  is  easy  without 
straining  the  arch  of  the  foot),  followed  by  fixation  in  an  over-cor- 
rected position  in  a  plaster  of  Paris  cast.  In  sucklings,  strapping  in 
over-corrected  position  for  six  months,  by  means  of  strips  of  adhesive 
plaster  may  give  good  results. 

234 


Bockenheimer,  Atlas. 


Tab.  CXVII. 


be 


Rcbman  Company,  New-York. 


Alter  the  niiitli  inontli  preliminary  tenotomy  of  the   tendo 

Achillis  is  necessary,  before  tlie  lout  eaii  be  brou;^lit  iuto  llie  proper 
position,  jukI  the  same  operation  is  indicated  whenever  correction 
cannot  be  obtained  witiiout  using  violence.  To  prevent  relapse  boots 
should  be  worn  with  the  sole  raised  on  the  outer  side,  but  care  must 
be  taken  to  avoid  producing  flat  foot.  In  varus  clubfoot  due  to  polio- 
myelitis, tendon  transplantation  may  be  performed.  Old-standing 
cases  of  clubfoot  in  adults  require  osteotomy  or  sometimes  even  more 
extensive  operations,  or  exarticulation. 


Fig.  145  shows  a  congenital  tumor  involving  the  lower  part  of 
the  riglit  cheek,  the  wjioie  right  side  aiid  the  greater  part  of  the  left 
side  of  the  neck.  The  skin  was  unchanged  and  movable  over  the 
tumor  which,  on  examination,  was  found  to  be  multilocular  and  cystic. 
There  was  no  diminution  on  pressure.  The  tumor  also  extended  to 
tlie  floor  of  the  mouth,  so  that  the  tongue,  which  was  considerably 
enlarged  (macroglossia),  owing  to  the  presence  therein  of  a  similar 
cystic  formation,  was  displaced  upward.  The  greenish  surface  of  the 
cyst  was  visible  under  tlie  mucous  membrane  of  the  mouth,  so  that 
the  diagnosis  of  congenital  multiple  cystic  lymphangioma  was 
made. 

The  term  himphangioma  should  be  resrtricted  to  those  tumors  in 
which  there  is  neoformation  of  lymphatic  vessels,  and  not  be  made  to 
include  simple  dilations  (lymphangiectases)  without  new  forma- 
tion. (This  distinction  is  identical  with  that  between  angiomata  and 
angiectases,  see  page  101).  Clinically,  we  divide  lympbangiomata 
into  single  and  multiple;  anatomically  into  simple,  cavernous  and 
cystic.    All  three  forms  are  often  present  in  the  same  patient. 

Lymphangioma  in  most  cases  is  congenital  or  appears  soon  after 
birth.  Its  site  of  predilection  is  the  subcutaneous  tissue;  but  is  also 
observed  in  the  skin,  muscular  interstices  and  subserous  tissue. 

Simple  himphangioma  is  common  in  the  tongue  or  lips  where  it 
forms  a  circumscribed  tumor  always  somewhat  adherent  to  the 
slightly  thickened  skin.  Sometimes  the  name  simple  lymphangioma 
is  wrongly  applied  to  lymphangiectases,  whicli  form  lolmlated 
growths  in  the  head,  trunk  and  limbs. 

Cavernous  Igmphangioma  is  always  a  painless,  diifuse.  slow- 
growing  tumor,  of  soft  consistency  and  with  a  smooth  surface  and 
irregular  outline,  adherent  to  the  overlying  skin  or  mucosa.  It  grad- 
ually decreases  under  pressure,  because  its  endothelium-lined  cavi- 

235 


ties  communicate  with  the  neighboring  lymph  vessels.  When  visible 
under  the  skin  or  mucosa,  it  imparts  to  the  latter  a  pale  green  hue, 
very  different  from  the  reddish  blue  color  of  cavernous  hemangioma 
(Figs.  36,  80  and  81).  In  the  cheeks,  tongnie,  and  lips  they  give  rise 
to  enlargement  of  these  parts  (macromelia,  macroglossia,  Fig.  145, 
and  macrocheilia).  In  the  neck  it  causes  a  dimpled  swelling  of  the 
skin,  owing  to  the  numerous  processes  which  it  sends  in  all  directions. 
(Fig.  145.)  As  already  mentioned,  lymphangiomata  may  be  situated 
over  encephaloceles  or  myelocystoceles.  Gradual  atrophy  of  the 
bones  may  be  caused  by  the  pressure  of  extensively  progressing  lym- 
phangioma. 

Cystic  lymphangioma  occurs  in  the  subcutaneous  or  intermuscular 
tissue,  most  often  in  the  lateral  cervical  region  (Fig.  145).  It  is 
composed  of  large,  cystic  endothelium-lined  cavities  containing  a 
whitish  or  brownish  fluid.  It  is  also  almost  always  congenital  and 
characterized  by  its  slow  growth,  which  may  cease  after  some  years. 
The  skin  is  unchanged  and  can  be  raised  from  the  tumor.  Fluctua- 
tion is  present,  but  there  is  no  diminution  of  the  tumor  on  pressure. 
Extensive  lymphangioma  of  the  neck  may  be  dangerous  from  pres- 
sure on  the  trachea.  Cystic  lymphangioma  may  also  occur  in  the 
axilla,  the  popliteal  space,  the  bend  of  the  elbow,  the  groin  and  the 
sacral  region.  Infants  with  congenital  lymphangioma  sometimes 
show  other  malformations,  and  are  often  incapable  of  surviving. 

Diagnosis 

Simple  lymphangioma  may  be  mistaken  for  fibroma,  lipoma  or 
hemangioma.  The  presence  of  transitional  stages  to  cavernous 
lymphangioma  in  some  cases  helps  the  diagnosis. 

Cavernous  lymphangioma  can  only  be  mistaken  for  hemangioma, 
as  no  other  tumor  diminishes  on  pressure.  It  differs  by  its  greenish 
color  (compare  Figs.  36,  80  and  81  with  Fig.  145)  and  the  nature 
of  its  contents. 

Cystic  lymphangioma,  when  occurring  as  a  single  multilocular 
cyst,  may  be  mistaken  for  various  tumors,  according  to  its  location : 
hlood  cyst,  branchial  cyst,  lipoma  or  dermoid. 

In  a  case  like  that  shown  in  Fig.  145,  on  account  of  the  situation 
of  the  tumor  on  both  sides  of  the  neck  in  the  submaxillary,  submental 
and  parotid  regions,  the  case  might  be  mistaken  for  an  affection  first 
described  by  Mikulicz,  in  which  there  is  symmetrical  enlargement 
of  all  the  salivary  glands  and  glands  of  similar  structure  in  the  head 
and  neck.    In  this  case,  however,  there  was  no  change  in  the  lacrymal 

236 


glands,  which  are  usually  affected  in  Mikulicz's  disease;  also  there 
was  a  characteristic  lymphangioma  in  the  tongue,  which  is  absent  in 
Mikxdkz's  disease.  The  swelling  of  the  floor  of  the  mouth  on  each 
side  of  the  frenum  of  the  tongue  also  resembles  a  ranula,  i.e.,  a  reten- 
tion cyst  of  the  sublingual  gland. 

The  prognosis  of  limited  forms  of  lymphangioma  is  not  bad;  it 
occasionally  undergoes  spontaneous  resolution. 


Circumscribed  lymphangioma  is  best  excised.  In  diffuse  caver- 
nous lymphangioma  (macrocheilia,  macroglossia,  macromelia)  cunei- 
form excision  may  be  performed.  The  introduction  of  magnesium 
in  the  cavity  to  cause  thrombosis  and  shrinking  of  the  tumor  may 
be  tried.  It  makes  extirpation  easier  and  avoids  infection  through 
a  lymph  fistula,  which  so  often  occurs  after  the  usual  operation. 
Radical  oj^erations  should  not  be  performed  unless  the  child  is  in 
good  condition.  Puncture  and  injection  of  tincture  of  iodine  are 
unsafe  measures,  while  lymph  fistulas  often  remain  after  incision 
and  packing.  Lymph  fistulse  must  always  be  removed  by  a  radical 
operation,  on  account  of  the  danger  of  infection  through  them. 
Lymph  fistulas  which  occur  from  injury  to  the  thoracic  duct  after 
extensive  extirpation  of  tuberculous  glands  of  the  neck  can  be  cured 
by  prolonged  packing. 


Fig.  146  shows  a  teratoma  of  the  left  side  of  the  face,  nearly 
as  large  as  the  fist,  involving  the  left  orbit  and  almost  the  whole 
of  the  buccal  cavity,  and  covered  by  livid,  movable  skin.  It  was  sur- 
rounded by  a  connective-tissue  capsule.  Further  examination  showed 
that  it  arose  from  the  base  of  the  skull,  but  did  not  communicate  with 
the  cranial  cavity.  The  tumor  was  soft  and  fluctuating  in  some  places, 
hard  in  others.  Investigation  by  the  X-rays  showed  the  presence  of 
a  piece  of  bone,  which  was  afterward  identified  as  part  of  the  upper 
jaw.  On  microscopical  examination  the  tumor  was  found  to  consist 
of  neuroglia,  neuroepithelium  and  cysts  lined  with  epithelium.  There 
were  no  other  malformations  present  except  mutilation  of  the  right 
ear.    Death  occurred  soon  after  birth. 

Teratomata  may  be  bigerminal  or  monogerminal.  In  bigerminal 
teratoma  there  is  a  true  double  formation — a  fetus  within  a  fetus. 
In  monogerminal  teratoma  all  the  tissues  are  derived  from  one  em- 
bryo only.    The  latter  includes  all  kinds  of  mixed  tumors,  which  are 

23r 


constituted  by  all  three  embryonic  layers  (epiblast,  mesoblast  and 
hypoblast).  Those  dermoid  cysts  which  are  formed  by  all  three  em- 
bryonic layers  belong  to  teratomata.  A  distinction  between  mono- 
germinal and  bigerminal  teratomata  is  not  always  possible,  and  is  of 
little  clinical  importance.  In  the  case  figured  in  Fig.  146,  as  the  mass 
consisted  of  epiblastic  products  only,  it  must  be  regarded  as  a  mono- 
germinal tumor  which  originated  from  a  separated  portion  of  the 
epiblast.  This  view  is  supported  by  the  fact  that  the  tumor  developed 
in  a  region  (base  of  the  skull)  where  epiblastic  inclusion  is  possible. 
On  the  other  hand,  it  appears  somewhat  arbitrary  to  consider  the 
tumor  as  a  bigerminal  teratoma  simply  because  of  its  large  size  at 
birth. 

Teratomata  are  rare  on  the  whole,  and  always  congenital.  They 
are  most  often  found  in  the  buccal  cavity,  where  they  may  be  mis- 
taken for  naso-pharyngeal  polypi  (Fig.  25).  They  also  occur  in  the 
face,  neck  and  coccygeal  region,  and  have  been  observed  in  the  medi- 
astinum and  abdominal  cavity.  They  may  attain  a  huge  size  and 
have  then  an  irregular,  uneven  surface.  The  consistency  also  varies, 
some  parts  being  cystic,  others  soft  and  others  hard.  Teratomata 
often  form  encapsulated  tumors.  They  may  cause  extensive  destruc- 
tion by  pressure  on  the  neighboring  parts.  A  distinction  between 
teratomata  and  teratoid  mixed  tumors  is  clinically  impossible.  The 
exact  pathological  diagnosis  in  many  cases  is  only  made  after  exam- 
ination of  the  extirpated  tumor. 

Diagnosis 

Teratomata  which  appear  as  large,  congenital  tumors  can  gen- 
erally be  recognized  by  the  above-mentioned  characteristics,  espe- 
cially by  their  situation  in  the  embryonic  fissures.  The  diagnosis  is 
assisted  by  the  X-rays,  which  frequently  reveal  the  presence  of  .bones 
and  teeth.  Teratomata  occurring  in  the  thorax,  abdomen  and  pelvis, 
especially  when  they  do  not  assume  a  tumor  growth  till  later  years, 
can  often  only  be  diagTiosed  by  operation.  Dermoid  cysts  of  the  ovary 
are  one  of  the  most  frequent  and  surgically  interesting  kinds  of 
teratoma. 

Treatment 

Teratomata  have  been  successfully  removed  both  in  children  and 
in  adults,  especially  those  of  the  ovary  or  testicle. 

Extensive  teratomata  of  some  regions  (Fig.  146)  cannot  be  re- 
moved by  operation.    Moreover,  the  presence  of  other  deformities, 

238 


Bockenheimer,  Atlas. 


Tab.  CXVIII. 


Rebman  Company,  New- York. 


such  as  spina  liilida,  aii<l  tiii'  feeble  condition  of  tbe  infants  often 
renders  operative  treatinciit  impossiljle. 

Fig.  147  shows  a  case  of  fistula  due  to  the  persistency  of  the 
omphalo-mesenteric  (or  vitelline)  duct;  that  is,  of  the  toniniuni- 
cation  lictwccii  IIk'  aliinciilaiy  canal  and  tlie  unil)ilical  vesicle,  or 
yolk-sac,  which  usually  disappears  about  tiie  ciLrhtii  week  of  fetal  life. 

When  it  persists,  it  is  known  as  Meckel's  diverticulum  and  is 
implanted  anywhere  on  the  small  intestine,  but  most  fre(|uently  about 
30  inches  above  the  ileocecal  valve.  Its  frequency  is  estimated  to 
2%  of  autopsies.  It  may  become  attached  to  the  umbilicus  or  even 
extend  for  a  short  length  into  the  umbilical  cord.  AVhen  the  latter 
is  tied  close  to  the  abdominal  wall,  the  diverticulum  is  pinched,  and 
when  the  cord  falls,  a  small  fistula  is  formed,  which  discharges  feces 
if  the  diverticulum  is  patent  throughout,  or  mucoid  secretion  if  only 
the  external  end  is  pervious.  Cystic  dilatations  may  develop  if  both 
ends  are  closed  and  the  middle  jiervious. 

Later  in  life  Meckel's  diverticulum  plays  a  not  unimportant  part 
in  abdominal  patholog}^  (Porter,  Balfour  of  Maya's  clinic).  It  is 
more  dangerous  than  the  vermiform  appendix.  Diverticulitis  therein 
is  not  rare:  about  2%  of  tlie  cases  of  intestinal  invagination  originate 
in  Meckel's  diverticulum;  again,  it  may  become  entangled  with  other 
loops  of  gut  and  cause  obstruction.  The  band  connecting  the  divertic- 
ulum with  the  navel  is  more  dangerous  in  this  respect  than  the 
diverticulum  itself. 

In  umbilical  fistula  due  to  Meckel's  diverticulum  a  red  globular 
swelling  is  seen  at  the  navel,  with  a  small  depression  at  its  apex.  The 
surface  of  the  swelling  is  formed  by  mucous  membrane.  A  probe 
can  be  passed  through  the  depression  as  far  as  the  small  intestine, 
if  the  whole  duct  is  open.  If  such  be  the  case,  the  gi-eater  jiart  of  the 
feces  are  discharged  through  the  fistula,  causing  infiannnation  of  the 
skin  surrounding  the  navel.  Death  often  occurs  from  prolapse  of  the 
small  intestine.  In  small,  incomplete  fistulae  there  is  no  such  danger 
and  the  only  inconvenience  is  that  of  slight  discharge  and  skin 
irritation. 

Diagnosis 

Septic  cunditio>ts  uf  the  )i(in'l  attended  by  granulation  tissue  for- 
mation somewhat  resemble  the  above-described  condition.  Umbilical 
fecal  fistulae  consecutive  to  ligation  of  the  cord  and  without  symptoms 
of  intestinal  obstruction  are  all  due  to  Meckel's  diverticulum. 

239 


There  are  also  umbilical  fistulce  due  to  other  causes,  e.g.  to 
persistency  of  the  urachus,  which  represents  the  remains  of  the 
communication  between  the  bladder  and  the  allantois  in  fetal  life, 
and  normally  becomes  obliterated  and  constitutes  the  median  liga- 
ment of  the  bladder.  Complete  patency  of  the  urachus  causes  a 
urinary  fistula;  incomplete  patency  a  cyst.  The  fistula  also  appears 
after  separation  of  the  umbilical  cord.  In  full-grown  subjects  the 
diagnosis  of  urachal  fistula  is  not  very  difficult,  as  it  may  be  helped 
by  cystoscopy,  and  injection  of  colored  fluids;  but  in  the  newborn, 
when  the  diagnosis  cannot  be  made  by  chemical  and  microscopical 
examination  of  the  secretion,  powdered  charcoal  should  be  given  by 
mouth:  in  case  of  vitelline  fistula  it  appears  at  the  navel;  in  case  of 
urachal  fistula,  it  does  not. 

In  adults,  tuberculosis  of  the  intestine  or  peritoneum,  actinomy- 
cosis, purulent  peritonitis,  empyema  of  the  gall  bladder  and  dermoids 
may  cause  umbilical  fistulae.  The  antecedent  history  often  makes 
the  diagnosis  clear;  but  we  must  remember  that  fistulae  due  to  per- 
sistency of  the  urachus  or  Meckel's  diverticulum  do  not  always  ap- 
pear at  birth,  but  often  only  late  in  life,  and  that  tuberculosis  of  a 
partially  patent  urachus  has  sometimes  been  seen  {Pearse  and 
Miller). 

Treatnient 

Fistula  of  the  vitelline  duct  can  sometimes  be  prevented  by  dis- 
covering the  condition  before  tying  the  umbilical  cord.  The  cord  is 
then  thicker  than  usual  at  its  base.  The  end  of  the  duct  can  then 
be  reduced  and  the  cord  tied  further  away  from  the  navel. 

In  cases  of  complete  fistula  leading  to  the  intestine  laparotomy 
is  necessary,  with  resection  of  the  diverticulum  and  suture  of  the 
intestine.  This  was  done  in  the  case  represented  in  Fig.  147,  but 
the  child  was  in  bad  condition  owing  to  the  prolapse  of  the  gut,  the 
evacuation  of  feces  from  the  navel  and  the  excoriations  of  the  sur- 
rounding skin,  and  the  operation  was  unsuccessful. 

Fistula  of  the  urachus  must  be  dissected  down  to  the  bladder  and 
excised,  after  that  the  bladder  is  sutured. 


Fig.  148  shows  a  large  congenital  umbilical  hernia  containing, 
as  is  often  the  case,  the  liver  and  intestines.  Such  hernise  are  fre- 
quently associated  with  various  forms  of  spina  bifida  or  exstrophy 
of  the  bladder.     Extensive  umbilical  hernia  occurring  at  birth  are 

240 


due  to  arrested  (Irx-cloiinicnl  aiid  ii miilctc  closui'c  ol'  the  iibdoiiiiiial 

walls. 

There  are  also  in  inl'aiils  iiinliili<'al  licnila'  rcsiill  ini;-  rr(jiii  a  lesser 
disturbance  oi'  evolution  ;  tiii'  abdominal  walls  are  closed,  the  umbilical 
rini;'  is  not  nnidi  widened,  the  hei'iiia  is  cylindrical  in  sha|)e,  not  lar^e, 
and  never  contains  anytliin.u:  but  small  intestine.  These  herniie 
are  frequent,  but  may  be  so  small  as  to  be  overlooked  at  birth,  and 
then  be  included  in  the  lii,^ature  of  the  umbilical  cord.  The  base  of 
the  latter  should,  therefore,  always  be  examined  to  see  if  it  contains 
intestine. 

Congenital  umbilical  h<'i-nia  forms  a  large  globular  sivelling  in  the 
region  of  the  navel  (Fig.  148).  'I'he  surface  is  destitute  of  cutaneous 
covering  and  shows  the  greenish-yellow  remains  of  the  amnion.  The 
remains  of  the  umbilical  cord  are  generally  seen  at  One  side  of  the 
swelling.  In  rare  cases  epidermization  takes  place  at  the  borders; 
more  connnonly  the  swelling  ruptures  from  pressure,  with  conse- 
quent i)rolapse  of  the  viscera  and  death  from  peritonitis. 

Diagnosis   and   treatment 

Both  types  of  congenital  umbilical  hernia3  are  so  characteristic 
that  they  cannot  be  mistaken  for  any  other  condition. 

The  occurrence  of  symptoms  of  intestinal  obstruction,  or  threaten- 
ing perforation  of  the  sac,  indicate  immediate  laparotomy,  with 
excision  of  the  sac,  reduction  of  its  contents  and  closure  of  the 
abdominal  walls.  In  some  cases  the  viscera  are  adherent  to  the  sac 
and  must  be  freed  by  dissection.  Reduction  of  the  visceral  contents 
is  sometimes  difficult  or  even  impossible,  especially  when  the  liver 
is  contained  in  the  sac.  If  operation  is  not  urgent,  it  may  be  post- 
poned till  the  child  is  stronger,  the  sac  being  supported  by  bandaging 
in  the  meantime.  The  results  after  these  operations  for  large  con- 
genital hernia^  are  not  very  favorable;  they  are  difficult;  there  is  not 
enough  abdominal  wall  to  allow  suture  without  great  tension  and 
pressure  on  the  viscera;  and  death  generally  occurs  soon  after  the 
operation,  as  happened  in  the  case  shown  in  Fig.  148, 

Most  of  the  hernia?  of  the  smaller  type  become  cured  without  any 
treatment.  The  placing  of  a  pad  of  cotton  over  the  umbilical  ring 
is  a  bad  practice,  because  it  only  tends  to  enlarge  the  ring.  In  older 
children  a  ]iersistent  umbilical  hernia  must  be  operated  on  as  in 
adults;  that  is,  I)y  dissection  and  excisimi  of  the  sai'  followed  In-  care- 
ful repair  of  the  abdominal  wall. 


241 


Fig.  149  shows  constrictions  of  the  fingers  due  to  amniotic 
adhesions.  This  is  a  mild  type  of  a  condition  that  may  go  as  far 
as  complete  absence  of  the  part  affected  (so-called  amniotic  amputa- 
tions). There  is  a  deep  circular  groove  extending  down  to  the  bone; 
but,  despite  this,  the  circulation  and  the  function  of  the  fingers  re- 
mained normal.  In  other  cases  there  is  often  elephantiasic  thicken- 
ing from  lymphatic  congestion.  In  some  cases  the  bones  are  con- 
stricted, as  shown  by  the  X-rays.  The  remains  of  the  amniotic  bands 
are  often  present  in  the  constricted  places. 

Other  malformations,  also  due  to  tightness  of  the  embryonic  mem- 
branes, are  syndactylia  (webbed  fingers),  harelip,  cleft  palate,  trans- 
verse fissure  of  the  cheek,  macrostomia,  and  fissure  of  the  tongue. 
In  the  case  represented  in  Fig.  149  there  was  also  harelip  and  cleft 
palate. 

More  extensive  varieties  of  malformation  of  the  extremities 
include  amelus  and  phocomehis.  In  amelus  the  extremities  are  absent 
or  only  represented  by  stumps.  This  condition  may  affect  all  four 
extremities,  both  arms  or  legs,  or  one  arm  or  leg.  In  phocomelus 
there  is  arrested  development  of  the  proximal  segments  of  the  arms 
or  legs,  or  of  all  four  extremities.  The  hands  or  feet  are  then  situ- 
ated directly  on  the  trunk.  Some  of  these  mutilated  individuals 
attain  adult  age,  and  one  has  been  known  to  live  to  sixty-two ;  several 
were  among  Barnum's  freaks. 

The  treatment  of  amniotic  constrictions  or  amputations  is  nil, 
except  esarticulation  of  the  useless  stumps  when  needed. 


Fig.  150  depicts  a  case  of  acromegaly,  a  condition  in  which  there 
is  enlargement  of  the  terminal  portions  of  the  body — hands,  feet,  nose, 
cheeks,  tongue  and  ears.  The  enlargement  affects  all  the  tissues  and 
does  ^ot  appear  till  after  the  termination  of  the  period  of  growth, 
thus  differing  from  congenital  giantism.  In  some  cases  there  is 
increased  growth  of  hair,  and  curvature  of  the  vertebral  column.  The 
disease  causes  considerable  disfigurement  of  the  face.  It  generally 
appears  between  the  twentieth  and  fortieth  years  and  may  remain 
stationary,  but  generally  increases  slowly.  In  many  cases  there  is, 
first  of  all,  hypertrophy  of  the  bones  of  the  hands,  feet  and  face. 

There  are  usually  headache,  visual  disturbances  and  more  or  less 
deterioration  of  the  mental  power. 

Acromegaly  has  been  traced  to  tumors  of  the  pituitary  body, 

242 


linckciila-iiiKT,  Atlas. 


Tab.  CXIX. 


V\ii.  149.    Ainpulalidiics  amnioticae. 


KehiiKin  Company,  New-York. 


Bockeiiheimer,  Atlas. 


Tab.  CXX. 


Fig;.  150.    Akromegalia  —  Makromelia  —  Makros'lossia. 


Rebnun  Coriipanj',  New- York. 


particularly  to  adenoma  of  the  anterior  lobe.  It  also  has  been  seen 
associated  with  persistency  of  the  cranio-pharyngeal  canal,  so  that  a 
congenital  maldevelopment  of  the  liyp()])liysis  may  Ik-  ,i  lacfdr  in  some 
cases.  Acromegaly  is  a  coiidition  due  to  hyperpituitarism,  while 
hypopituitarism  liriiigs  almnt  Frohlich's  adiposo-genital  syndrom 
(Cushiiig). 

Tumors  of  the  pituitary  body  can  l)e  demonstrated  by  the  X-rays, 
which  show  a  widening  of  the  sella  turcica.  Large  tumors  of  the 
pituitary  body  may  press  on  the  optic  and  ocular  nerves. 

Diagtiosis 

Partial  giantism,  which  also  begins  in  the  hands  and  feet,  differs 
from  acromegaly  by  being  congenital.  In  leontiasis  ossea  there  is 
enlargement  of  the  bones,  while  the  soft  parts  are  more  often 
atrophied,  and  the  enlargement  is  predominant  in  the  bones  of  the 
face,  not  in  the  lower  jaw. 

Acromegaly  aflPecting  one  extremity  only  might  be  mistaken  for 
osteitis  or  arthritis  deformans  or  for  chronic  osteomyelitis,  as  there 
may  be  lengthening  of  the  bone  in  both  these  diseases. 

Acromegaly  differs  from  elephantiasis  in  the  presence  of  enlarge- 
ment of  the  bones,  which  can  be  shown  by  the  X-rays.  Acromegaly 
commencing  in  the  face  might  possibly  be  mistaken  for  tumor  of  the 
upper  maxilla,  but  there  is  usually  early  hypertrophy  of  the  cheeks 
(macromelia),  lips  and  tongue  (macroglossia),  and  of  the  hands  and 
feet. 

Acromegaly  is  sometimes  impossilije  to  distinguish  from  the  bone 
hypertrophy  that  occurs  in  a  few  cases  of  syringomyelia,  and  it  is  not 
unlikely  that  some  of  the  cases  reported  as  acromegaly  without  pitui- 
tary tumor  were  indeed  syringomyelia. 

Treat  incut 

As  acromegaly  often  markedly  imjiairs  tlie  mental  efficiency,  an 
active  treatment  is  indicated,  even  if  the  ]irogress  of  the  disease 
is  slow. 

The  coiKlitinii  hi'ing,  as  it  is,  due  to  pituitary  hypersecretion, 
opotherapy  by  i^tuitary  extract  is  not  rational.  Partial  hypophy- 
sectomy  (Cushing,  v.  Eiselsherg,  Halstead,  Kanavel)  has  .siven 
notable  subjective  imiirovenient,  and  the  outlook  in  this  direction  is 
hopeful. 

No  treatment  was  applied  in  the  case  represented  in  Fig.  150. 


243 


INDEX  OF  AUTHORS 


Abbio.  5. 
Addis,  104. 
V.  Angerer,  37. 

Balfoi'ij.  -jriO. 

Bau.anci:,  -208. 

Barney,  203. 

Beck.  rfi.  102. 

Beebe.  fil. 

Beer,  C2. 

Bei.field.  202. 

V.   BlCRGMANN,   5,  35. 

Bernueim,  216. 

DE  Beiirmaxn,  18G. 

Bier,  SO,  120,  137. 

BlXNIE,  111. 

Beoodgood,  20,  43. 

BocKEKiiEiJiER,  130,  155,  228. 

BODINE,   14. 
BOECK,  30. 
BoRST,  52. 
Brajian,  23. 
Brewer,  158. 
Bruck,  43. 

Cauhei,.  0],  110. 
Cobb,  So. 
COLEY,  30,  131. 
Cotton,  158. 
Crile,  61. 
Cunningham,  158. 
Gushing,  243. 

Daviios.  208. 
Dercu.m,  70. 
Dietrich,  23. 
DowD,  104. 
DUI'UYTREN,  42,  81. 


V.  El.SEI.RBERG.  43,  243. 

EnnMcii.  117. 

Finney,  111. 
FiNSEN,  10. 
FOCIIIER,  163. 
FORDYCE,  187. 
FOURNIER,  10,  177. 

Fox,  180. 
Freeman,  83. 
Fuller,  168,  171. 

Garre,  148. 
Gibbon,  110. 
GoLGi,  52. 
gougerot,  186. 

Hagner,  121. 
Halstead,  243. 
Halsted,  17,  111. 
Hare,  111. 
Hawkins,  23. 
Hektoen,  186. 
HiBBS,  197. 
Hoffmann,  178. 

HOMANS,  153. 
Hubbard,  208. 
Huntington',  83. 
HuTCiiixsox,  80,  183. 

Joiixsox,  223. 
JoxES,  86. 

Kanavel,  243. 
Kaposi,  3,  38,  177. 
Kauffmann,  22. 
Keen,  85. 
Kelly,  71. 
Kkyes.  Jr.,  62,202. 


245 


KitlANI,  91. 

Klapp,  120. 
KocHER,  85,  194. 
kollaczek^  52. 
Keomatek,  80. 

Lane,  91. 
Langenbeck,  33. 
Lexer,  23,  83. 
Lusic,  111. 
Lyle,  91. 

Mace  WEN,  153. 
Mackee,  5,  80,  219. 
Mantoux,  190. 
Matas,  110,  111. 
Mato,  60. 
McCallum,  61. 
Metchnikoff,  117. 

MiCHAELIS,  43. 

Mikulicz,  236. 

MiXTEE,  54. 

Moeel-Lavallee,  99. 
moeeschi,  99.  . 
MoEO,  190. 

MOSETIG,  153. 

NoGUcni,  178,  185. 
O'Neill,  170. 

Parrot,  89,  177,  183. 

Partsch,  35. 

Pasteur,  174. 

Pate,  48. 

Peaese  and  Miller,  239. 

Peekins,  186. 

V.  PlEQUET,  190. 
PORTBE,   239. 

Powers,  83. 

PusEY,  5,  10,  51,  94,  104. 


Eavaut,  179. 

V.  Eecklinghausen,  82,  93. 

Eobinson,  5. 

EosE,  59. 

Euggles,  23. 

Sahli,  104. 
Sayre,  86. 
schaudinn,  178. 

SCHENCK,  186. 

Schmidt,  171. 
schuchaedt,  18. 
schultze,  43. 
schurman,  14,  20. 
Schwartz,  170. 
Sheeman,  85. 
Sheeman,  Wm.  O'N".,  91. 
Sheewell,  5. 
Stelwagon,  177. 
Stetten  (De  Witt),  213. 
Stewart,  208. 

Thomas,  83. 

ViECHOW,  66. 
Volkmann,  14,  20,  31,  83. 

Waldeyer,  52. 
Walker,  202. 
Wassermann,  89,  184. 
Weil,  104, 106. 
Welch,  106. 

AYlETING,  208. 

Willy  Meyer,  17. 
Wolff,  64. 

Young,  202. 

ZlEGLER,  102. 


246 


INDEX  OF  SUBJECTS 


Ordinary  figures  refer  to  pages  of  text. 
Black  figures  refer  to  number  of  illustrations. 


Abscess, 
Bone,  190. 

Breast,  123,  124,  85,  86. 
Cervical,  143,  174,  102,  114. 
Cold,  190. 

Gummatous,  181,  121. 
Lymph  gland,  143,   1G6,   174,  102, 

110,  114. 
Metastatic,  157,  108. 
Subcutaneous,  123,  55. 
Subperiosteal,  148. 
Thrombophlebitic,  122,  84. 
Tuberculous,  190. 
Acne  rosacea,  95,  70. 
Acromegaly,  243,  ISO. 
Actinomycosis,  175,  115,  116. 
Adenoids,  34. 

Adenoma  sebaceum,  50,  38. 
Adenoma  sudoriparum,  51. 
Adenophlegmon.     See  Abscess,  lymph- 
gland. 
Amniotic  constrictions,  242,  149. 
Ankylosis, 

Bony,  200,  127. 
Fibrous,  199,  125. 
Aneurysm,  arterial,  108,  82. 
Angina,  Ludwig's,  143. 
Angioma, 

Cavernous,  47,  101.  36,  80. 
Cutaneous,  101,  75,  81.     See  also 

Ntevi,  vascular. 
Subcutaneous,  101,  5/. 
Tongue,  47,  36. 
Angiosarcoma,  cheek,  35,  26. 
Anthrax,  172,  112,  113. 


Arm, 

Gunshot  wound,  lOG,  78. 
Lipoma.     See  also  Humerus. 
Arteriosclerosis,  212. 
Arthritis, 

Gonorrheal   (wrist),  168,  111. 
Gouty  (fingers),  222,  141. 
Syphilitic,  182. 
Tuberculous, 

Fibrous,  200,  127. 
Fungoid,  199,  125. 
Purulent,  199,  126. 
Asphyxia, 
Local  {Ray7iaud's disease),  215,  139. 
Traumatic,  107,  79. 
Barlow's  disease,  105. 
Basal-celled  cancer,  4. 
Beck's  paste,  192. 
Bedsores,  211. 
Bone, 

Abscess,  150. 

Acute  intlammations,  147,  104, 105, 

106,  107. 
Sarcoma,  41,  32. 
Syphilis,  181, 122. 
Tuberculosis,  194,  130,  131.     See 
also  Arthritis,  tuberculous. 
Botriomycosis,  35. 
Breast, 

Abscess,  123,  124.  85,  86. 
Carcinoma,  18,  10  lo  16. 
Fibroadenoma,  48,  37. 
Sarcoma,  38,  29,  30. 
Bubo,  Inguinal,  166,  110. 
247 


Burns,  217,  136. 
X-ray,  319,  138. 
Carcinoma  on  scar,  24,  20. 
Bursitis,  prepatellar,  56,  42. 
Cancer  en  euirasse,  19,  14,  15.     See 

also  Carcinoma. 
Cancroid,  5. 

Carbolic  gangrene,  211,  13S. 
Carbuncle,  135,  89. 
Carcinoma, 

Branchiogenous,  31. 
Breast,  18,  10. 
Breast  (male),  IS,  11. 
Face,  3,  1. 
Forehead,  5,  2. 
Hand  (sear),  34,  22. 
Hand  (wart),  34,2/. 
Leg  (burn),  24,  20. 
Lip,  6,  3. 

Lip  (and  lupus),  9,  5. 
Mastitoides,  20,  16. 
Melanotic,  25,  23. 
Nipple,  18,  12. 
ISTose,  6,  4. 
Penis,  22,  19. 
Scalp,  20,  31,  17,  18. 
Skin,  1,  2,  20,  21,  22. 
Tongue,  10,  7,  8,  9. 
■Caries  sicca,  195. 
•Cattle  fever,  173. 

Cavernoma.     See  Angioma,  cavernous. 
Chancre,    Syphilitic,    of    tongue,    178, 

118. 
Cheek, 

Actinomycosis,  175, 115. 
Cutaneous  horn,  50,  38. 
Chilblain,  320. 
Chimney  sweep's  cancer,  23. 
Chondroma,    multiple,    of   fingers,    66, 

SO. 
Chondroxyxosarcoma,  45,  34. 
Claw-hand,  ulnar,  82,  62. 
■Coley's  fluid,  30. 
■Condylomata, 
Acuminata,  23. 
Lata,  68. 


Congelation.     See  Frostbite. 
Contraction,  Dupuytren's,  81,  60.    See 

also  Eetraction. 
Corns,  87,  140,  64,  100. 
Cutaneoi;s.     See  Skin. 
C)'stadenoma,  Breast,  48,  37. 
Cystosareoma,  Breast,  38,  30. 
Cysts.    See  Dermoids,  Ganglion,  Goiter, 

Lymphangioma,  Sebaceous. 
Dermoid  cysts. 
Forehead,  62,  46. 
Neck,  62,  48. 
Foreskin,  62,  47. 
Detachment  of  skin,  99,  73. 
Diabetic  gangrene,  313,  140. 
Duct,    persistence    of    omphalo-mesen- 

teric,  339,  147. 
Dupuytren's  contraction.     See  Contrac- 
tion. 
Ecchymoses,  104, 106,  107,  77,  78,  79. 
Eczema  of  nipple.    See  Paget's  disease. 
Elephantiasis, 
Foot,  97,  72. 

Nerves.  See  RecMingliausen's  disease. 
Penis,  96,  71. 
Encephalocele,  337,  142. 
Enchondroma.     See  Chondroma. 
Endarteritic  gangrene,  306. 
Endothelioma, 
Face,  51,  39. 
Parotid,  53,  40. 
Epithelioma.     See  Carcinoma,  Squam- 

ous-celled. 
Epulis,  46,  35. 
Erysipelas, 

Bullous  hemorrhagic,  131,  91, 
Chronic,  130. 
Erythematous,  139,  90. 
Eecurrent,  130. 
Erysipeloid,  133,  92. 
Exostoses, 

Malignant,  45. 
Subungual,  139. 
248 


Face, 

Actinomycosis,  175.  115. 
Angiosarcoma,  35,  26. 
Anthrax,  172,  112,  113. 
Carcinoma,  3,  5,  7,  2. 
Ecchymoses,  104,  77. 
Endothelioma,  51,  39. 
Erysipelas,  129,  90. 
Horn,  50,  38. 
I\IaU'ormations.    See  Acromegaly. 

Teratoma. 
Nseviis,  101,  76. 
Sarcoma,  36,  27. 
Rodent  ulcer,  3,  /. 
Teratoma,  237,  146. 
Fascia, 

Gangrene,  209,  134. 
Sarcoma,  44,  33. 
Fibroadenoma.    See  Breast. 
Fibrolipoma,  69,  52. 
Fibroma  of  tendon  sheath,  64,  49. 
Fingers.      See    Chondroma,    Carbolic 
gangrene,   Amniotic  constrictions. 
Arthritis      (gouty).      Claw-hand, 
Paronychia,      Eetraction,      Spina 
ventosa.  Whitlow. 
Fistula, 

Actinomycotic,  175,  116. 
Congenital, 
Neck,  76,  57. 
Umbilicus,  239,  147. 
Urachus,  240. 
From  foreign  body,  75,  56. 
Osteomyelitio,  154,  156,  104,  106, 

107. 
Tuberculous,  190,  192,  125. 
Flat  foot,  113,  83. 
Foot,  Melanoearcinoma,  25,  32.     See 
also    Corns,    Gangrene,    Toe-nail 
(ingrowing).  Phlegmon,  Perforat- 
ing ulcer.  Varus. 
Forearm, 
Detachment  of  skin,  99,  73. 
Gummatous  osteitis,  182,  122. 
Sarcoma,  44,  33. 


Forehead, 

Carcinoma,  5,  2. 

Dermoid  cy.st,  62,  46. 
Foreskin.     See  Dermoid  cysts. 
Fracture, 

Greenstick,  88,  65. 

Ununited,  90,  66. 
Frostbite,  220,  137. 
Furuncle,  125,  87. 
Fnrunculosis,  125,  89. 
Ganglion  of  wrist,  55,  41. 
Gangrene, 

Angioneurotic.     See  Raynaud's  dis- 
ease. 

Angiosclerotic,  205. 

Carbolic,  211,  135. 

Diabetic,  212, 140, 

Embolic,  205. 

Gaseous,  163,  109. 
General  infection,  157,  108. 
Geographical  tongue.     See  Glossitis. 
Glossitis,  Marginate,  177,  117. 
Goiter, 

Cystic,  58,  44. 

Exophthalmic,  60. 
Gonorrheal  arthritis.     See  Arthritis. 
Gouty  arthritis.     See  Arthritis. 
Grafts.    See  Skin. 
Granulations,  75,  55. 
Gumma, 

Abscess,  181.  121. 

Bone,  182,  122. 

Lip  and  nose.  ISl,  120. 

Skin,  181,  121. 

Tongue,  182,  119. 

Ulcerated,  181,  120,  122,  123. 
Halhis  valgus,  87.  64. 
Hammer  toe,  87,  64. 
Hand, 

Burns.  21?.  136. 

Carcinoma,   24.  21,  22. 

Enchondroma,  66,  SO. 

Frostbite,  220,  137. 

Tuberculosis,  201.  130. 
ll.'inai-throsis  of  wrist,  82,  62. 
249 


Hematoma.      See   Arm    (Gunshot   in- 
jury), Hemopliilia,  Othematoma. 
Hemophilia,  104,  77. 
Hemorrhage   from   compression.      See 

Asphyxia  (traumatic). 
Hemorrhoids,  67,  51. 
Hernia,  umbilical,  240,  148. 
Hidrosadenitis,  128. 
Hip,  Tuberculosis,  199,  125. 
Hodghin's  disease,  30. 
Horn,  Cutaneous,  50,  38. 
Housemaid's  knee,  57. 
Humerus, 

Chronic  osteomyelitis,  156,  106. 

Sarcoma  of  upper  end,  40,  32. 
Hydrops,  Tuberculous,  195. 
Hygroma,  57,  43. 
Infections, 

Acute  pyogenic.  111,  84  io  114. 

Chronic,  175,  115  to  131. 
Interdigital.     See  Whitlow. 
Ischemic.     See  Retraction. 
Jaw, 

Actinomycosis,  175,  116. 

Osteomyelitis,  154,  105. 

Periostitis,  145,  103. 

Sarcoma.     See  Epulis. 
Keloid, 

After  laparotomy,   79,  59. 

After  vaccination,  79,  58. 
Knee,  Tuberculosis,  199,200, 125, 127, 
128.    See  also  Bursitis,  Chondro- 
myxosarcoma,  Hygroma. 
Leg, 

Carcinoma,  24,  20. 

Fracture,  90,  66. 

Varicose  ulcer,  97,  72. 
Leucoplakia  of  the  tongue,  10,  8,  9. 
Lip, 

Carcinoma,  6,  3. 

Carcinoma  and  lupus,  9,  5. 

Gumma,  181,  120. 


Lipoma, 

Pendulous,  69,  52. 

Subcutaneous,  69,  52. 

Symmetrical,  69,  52. 
Lupus,  9,  5. 
Lymphadenitis, 

Cervical,  143,  174,  102,  114. 

Inguinal,  166,  110. 

Tuberculous,  192,  124. 
Lymphadenoma.     See  Hodghin's  dis- 
ease. 
Lymphangioma,     Multiple     cavernous 

cystic,  235,  145. 
Lymphangitis,  127,  87. 
Lymphoma,  malignant.    See  Hodghin's 

disease. 
Lymphosarcoma,  30,  24. 
Macrocheilia,  242,  150. 
Macroglossia,  235,  242,  145, 150. 
Macromelia,  242,  150. 
Malformations,  congenital,  227,  142  to 

149. 
Malignant  Pustule.    See  Anthrax. 
Mastitis, 

Carcinoma tosa,  20, 16. 

Puerperal,  124,  86. 
Meckel's  diverticulum.     See  Duct,  per- 
sistence of. 
Melanoearcinoma,  25,  23. 
Melanosareoma,  36,  28. 
Meningocele,  231. 
Mikulicz's  disease,  236. 
Mixed  tumor,  53,  40. 
Mycosis  fungoides,  39. 
Mummification,  209,  133. 
Myelocele,  229,  143. 
Myelocystocele,  230,  144. 
Myxcedema,  60. 
Myxolipoma,  234,  144. 
Nsevi, 

Carcinomatous  desreneration,  20,  17. 


250 


NiKvi — Continued. 
Hairy,  92,  67. 
Neuromatosus.     See   Rechlinghhau- 

sen's  disease. 
Pigmentary,  93,  67. 
Vascular,  101,  76. 
Verrucosus,  92,  67. 
Nasopliaryngeal  polypi,  33. 
Neck, 

Abscess,  143,  174,  102,  114. 
Angioma,  101,  75. 
Carbuncle,  125,  89. 
Fistula,  7G,  57. 
Furuncle,  125,  87. 
Necrosis, 

Of  fascia,  209,  133. 
Of  tibia,  156,  107. 
In  osteomyelitis,  148,  149. 
Neosalvarsan,  187. 
Nerve, 

Compression.    See  ,Claw-hand. 
Elephantiasis.    See  Recklinghausen's 
disease. 
Neurofibromatosis.  See  Neuroma,  Rech- 

linghausen's  disease. 
Nose,  carcinoma,  G,  4. 

gumma,  181,  120.     See  also  Ehino- 
phyma. 
Omphalo-mesenteric  duct.     See  Duct. 
Onychogryposis  212,  140. 
Orbit,  sarcoma,  36,  27. 
Osteitis, 
Deformans,  243. 
Gummatous,  182,  122. 
Tuberculous,  201,  130,  131.     See 
also  Spina  ventosa. 
Osteomyelitis, 
Acute,  147.  105. 
Chronic,  104,  106,  107. 
Humerus,  155,  106. 
Jaw,  154,  104. 
Scapula,  155,  105. 
Tibia,  156,  107. 
Osteosarcoma,  41. 

Humerus,  40,  32. 
Othematoma,  99,  74. 


Pagel's  disease,  19,  13. 
Panaritium.     See  Wliitlow. 
Papilloma, 
Skin,  CI,  45. 
Tongue,  10,  6,  7. 
Parotid.     See  Endothelioma. 
Paronychia,  138,  98. 
Parulis.    See  Jaw,  periostitis. 
Pediculosis,  174, 114. 
Penis, 

Carcinoma,  22,  19. 
Elephantiasis,  96,  71. 
Perforating  ulcer  of  foot,  215,  139. 
Periostitis,  alveolar.     See  Jaw,  perios- 
titis. 
Pernio.     See  Chilblain. 
Phagocytosis,  117. 
Phlebitis,  122,  84. 
Phlegmon, 

Gaseous,  163,  109. 
Gangrenous,  141,  101. 
Neck,  143,  102. 
Putrefactive,  141,  101. 
Submaxillary,  143,  102. 
Woody,  144. 
Phosphorous  necrosis,  154. 
Pigmentar}',  Nsevi.    See  Nsevi. 
Carcinoma.     See  Melanocarcinoma. 
Sarcoma.    See  Melanosarcoma. 
Polypus,   malignant  nasal.     See  Sar- 
coma, epipharyngeal. 
Prepuce.    See  Foreskin. 
Prepatellar.    See  Bursitis. 
Pseudarthrosis.       See     Fracture,    un- 

imited. 
Pseudoleukemia.     See  Ilodgl-in's  dis- 
ease. 
Puerperal.     See  Mastitis. 
Pustule,  malignant.     See  Anthrax. 
Rachitis,  88,  65. 
Raehischisis.  227,  742. 
Ragnaucl's  disease,  215,  139. 
Recklinghausen's  disease,  92,  68,  69. 
Rhinophyma,  95,  70. 
Retraction, 

Cicatricial  of  finger,  82,  61. 


251 


Dupuytren's,  81,  60. 

Ischemic,  88,  63. 
Salvarsan,  187. 
Sarcoids,  38. 
Sarcoma, 

Bone,  41,  32. 

Breast,  38,  29-30. 

Epipharj'ngeal,  32,  25. 

Fascia,  44,  33. 

Giant-celled.     See  Epulis. 

Melanotic.     See  Melanosarcoma. 

Orbit,  36,  27. 

Skin,  multiple,  38,  31. 
Scalp, 

Carcinoma,  20,  17. 

Sebaceous  cysts,  21,  18. 
Scars,  hypertrophic.     See  Keloid. 
Sebaceous  cysts.    See  Scalp. 
Skin, 

Carcinoma,  1,  2,  20,  21,  22. 

Detachment,  99,  73. 

Endothelioma,  51,  39. 

Gangrene,  209,  134. 

Gumma,  181,  121. 

Grafts,  7.5,  5S. 

Horn,  50,  38. 

Papilloma,  61,  45. 

Sarcoma,  38,  31. 

Tuberculosis.    See  Lupus. 
Spina  bifida.      See  Myelocele,   Myelo- 
cystocele, Meningocele. 
Spina  bifida  occulta,  231. 
Spina  ventosa,  201,  131. 
Spirocheta  pallida,  178. 
Syphilis,  178.    See  Chancre,  Gumma. 
Telangiectases,   101,  81. 
Tendon.    See  Eetraction,  cicatricial. 
Tendon  sheath. 
Fibroma,  64,  49. 

Suppuration.     See  Whitlow,  tendin- 
ous. 
Tuberculosis,  201,  131. 
Teratoma,  237,  146. 
Testicle,  tuberculosis,  202,  129. 
Thrombo-phlebitis,  122,  84. 
Toe  nail,  ingrowing,  139,  99. 


Tongue, 

Carcinoma,  10,  7,  8,  9. 

Chancre,  178,  118. 

Geographical,  177,  117. 

Gumma,  182,  119. 

Leukoplakia,  10,  8,  9. 
Tophi.     See  Arthritis,  gouty. 
Tuberculosis, 

Bone,  194,  130,  131. 

Hand,  202,  131. 

Joints,  anlcle,  199,  125,  126.     See 
also  Hip  and  Knee. 

Lymph  glands,  192,  124. 

Skin.    See  Lupus. 

Testicle,  202,  129. 
Tumor, 

Albus.    See  White  swelling. 

Mixed.     See  Endothelioma,  parotid. 
Ulcer,  Decubital.     See  Bedsore. 

Gummatous.     See  Gumma. 

Molle,  166. 

Eodent,  3,  1. 

Varicose,  97,  72. 
Umbilical.     See  Fistula,  Hernia. 
Urachus.     See  Fistula. 
Varices,  111,  83. 
Varus,  234,  143. 
Vascular  nasvus.     See  Naevus. 
Wart.     See  Nsevus,  pigmentary;  also 
Carcinoma  (hand)  and  Melanocar- 
cinoma. 
White  swelling,  200,  128. 
Whitlow, 

Articular,  136,  95. 

Interdigital,  135,  97. 

Osteal,  136,  95. 

Periungual.    See  Paronychia. 

Subcutaneous,  134,  94. 
Subepidermic,  134,  93. 

Tendinous,  135,  96. 

V-shaped,  135. 
Woody  phlegmon  of  neck,  144. 
Wrist, 

Ganglion,  55,  41. 
Gonorrheal  arthritis,  168,  111. 
X-ray  burn,  219,  138. 
252 


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New  York. 

"  Prof.  Pels-Leusden  has  written  here  a  very  satisfactory  work  dealing: 
largely  with  present-day  German  surgical  practice,  and  the  completeness  of 
the  same  is  well  shown  from  the  study  of  any  one  chapter  taken  at  random, 
such  as  that  on  anesthesia  in  the  first  part  of  the  book,  in  which  we  are  fur- 
nished with  a  detailed  resume  of  a  great  many  more  methods  than  are  contained 
in  the  average  surgical  te.xt-book.  The  same  may  be  said  of  the  rest  of  the 
book's  contents." — Medical  Record. 


RUMPEL — Cystoscopy  as  Adjuvant  in  Surgery.  With  an  Atlas  of  Cysto- 
scopic  Views  and  Concomitant  Text  for  Physicians  and  Students. 
By  Staff  Surgeon  Dr.  0.  Rumpel,  Lecturer  in  Surgery  at  the  Uni- 
versity of  Berlin.  Only  Authorized  E')iglish  Translation  by  P.  W. 
Shedd,  M.D.,  Neiv  York. 

"The  illustrations  are  excellent  color  reproductions  of  the  images  presented 
In  the  most  common  tj^pes  of  bladder  lesions." — American  Journal  of  Surgery. 

"The  cystoscopic  drawings  are  extremely  good  and  portray  nature  faithfully. 
The  text  contains  much  sound  surgical  advice.  This  is  not  only  an  excellent 
atlas  but  it  will  aid  the  operator  in  many  instances  correctly  to  interpret  his 
findings.  This  book  should  have  a  place  in  every  cystoscopist's  library,  since 
it  is  not  only  an  excellent  atlas,  but  will  aid  the  operator  in  many  instances 
correctly  to  interpret  his  findings." — Medical  Record. 

"With  22  Textual  Figures  and  85  Illustrations  in  Color  on  36  Plates 
One  quarto  volume,  half  leather.    Price,  $8.50. 


REBMAN'S  RECE^fT  WORKS  ON  SYPHILIS 

BRESLER— The  Treatment  of  Syphylis  by  the  Ehrlich-Hata  Remedy 
(Dioxydiamidoarsenobenzol).  By  Dr.  Johannes  Bresler,  Physi- 
cian-in-Chief  to  the  Provincial  Asylum  at  Ltibeck.  Translated  by 
Dr.  M.  D.  Eder,  who  has  added  an  Appendix. 

Second  edition,  much  enlarged,  with  portraits  of  Ehrlich  and  Schaudinn. 
Cloth.     Price,  $1.00 

EHRLICH— The  Experimental  Chemotherapy  of  Spirilloses.  (Syphilis, 
Relapsing  Fever,  Spirilloses  of  Fowls,  Frambaesia.)  By  Paul 
Ehruch  and  S.  Hata.  With  contributions  by  Drs.  H.  J.  Nichols, 
New  York;  J.  Iversen,  St.  Petersburg;  Bitter,  Cairo;  Dreyer, 
Cairo.  Translated  by  A.  Newbold  and  revised  by  Robert  W. 
Felkin,  M.D.,  F.R.S.E.,  etc. 

■With  34  tables  in  the  text  and  5  plates.    About  200  pp.     Cloth,  $4.00 

FOURNIER— Treatment  and  Prophylaxis  of  Syphilis.  By  Alfred  Four- 
NIER,  Professor  at  the  Faculty  of  Medicine,  Member  of  the 
Academy  of  Medicine,  Physician  to  the  St.  Louis  Hospital,  Paris. 
Only  authorized  English  Translation  of  the  Second  Edition  by  C. 
F.  Marshall,  M.D.,  F.R.C.S.  American  edition,  revised  and  cor- 
rected with  an  appendix  by  George  M.  MacKee,  M.D.,  Instructor 
of  Dermatology  at  the  New  York  University  and  Bellevue  Hospital 
Medical  College. 

"The  name  of  Alfred  Foumier  has  been  so  long  known  in  connection  with 
syphilis  that  anything  which  emanates  from  his  pen  cannot  be  anything  but 
•  good." — American  Journal  of  Dermatology. 

"The  book  consists  really  of  the  two  most  recent  publications  of  the  well- 
known  French  author.     We  are  glad  to  see  it."— A'eu-  York  Medical  Journal. 

"Dr.  Marshall  is  to  be  congratulated  on  his  skill  in  converting  Professor 
Foumier's  brilliant  French  into  clear  and  attractive  English." — Medical  Record. 
630  pp.     Clo;h,  $3.00 

WECHSELMANN— The  Treatment  of  Syphilis  with  Salvarsan.  By  Sani- 
TATSRAT  Dr.  Wilhelm  Wechselmann,  of  Berlin;  Medical  Director 
of  the  Skin  and  Venereal  Disease  Section,  Rudolph  Virchow  Hos- 
pital, Berlin.  With  an  introduction  by  Professor  Dr.  Paul 
Ehrlich,  of  Frankfurt-on-Main;  Director  of  the  Royal  Institute 
for  Experimental  Therapeutics,  Frankfurt.  Only  authorized  trans- 
lation by  Abraham  L.  Wolbarst,  M.D.,  of  New  York.  Revised 
edition, 'with  an  appendix,  bringing  the  literature  up  to  date,  by 
Abr.  L.  Wolbarst,  M.D. 

"With  16  plates  (24  Figs.)  in  colors,  8  x  lOJ  inches,  and  19  textual 
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SURGICAL   OPERATIONS 

A    HAND  BOOK    FOR 

STUDENTS  AND   PRACTITIONERS 

BY 

PROF.    FRIEDRICH    PELS-LEUSDEN 

CHIKK    Sl'lUlEOM    TO    THE    I'MVERSITY     SURGICAL    CLINIC    AND    CHIEF    OF    THE 

UNIVERSITY    SURGICAL    POLYCLINIC    IN    THE    ROYAL    CHARITY 

HOSPITAL    OF    BERLIN 

OXLV  AUTHORIZED  ENGLISH  TRANSLATION 
BY 

FAXTON  E.  GARDNER,  M.D. 

NEW    YORK 

WITH    SIX    HUNDRED    AND    SIXTY-EIGHT    ILLUSTRATIONS 


*'^S^ 


N  E  VV     YORK 
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PUBLISHERS'   ANNOUNCEMENT 

This  is  a  practical  book  written  by  a  practical  man,  with  a  practical 
aim  in  view.  It  does  not  claim  to  be  a  system  of  great  "Operative  Tech- 
nique" in  which  all  techniques  are  set  forth  exhaustively,  in  which  every 
detail  is  described  and  discussed  at  full  length.  Nor  is  it  claimed  that 
the  reading  of  it  will  suffice  to  make  a  trained  surgeon  of  a  beginner. 
But  it  does  give  in  a  compact  form,  that  makes  the  handling  of  the  book 
easy,  a  remarkable  amount  of  surgical  "meat."  It  reflects  the  teachings 
otf  many  years  of  a  man  who  has  given  to  a  number  of  German  practi- 
tioners the  bulk  of  what  they  know  in  surgery. 

This  handbook  gives  all  the  information  needed  to  enable  a  man  who 
is  not  a  specialized  surgeon,  but  who  may  be  called  upon  at  any  time  to 
do  surgical  work,  to  understand  what  is  indicated  in  a  given  case,  and 
to  carry  out  the  contemplated  procedure.  All  this  is  set  forth  in  the 
essentials  without  any  superfluous  details.  It  is  a  treasure-trove  of  in- 
formation. 

For  the  surgeon,  more  trained  already  in  the  art,  the  book  is  interest- 
mg  in  that  it  represents  the  typical  German  teachings  of  the  day.  While 
the  general  principles  of  Surgery  remain  the  same  the  world  over,  things 
are  not  done  exactly  in  the  same  way  in  the  different  Countries;  and  get- 
ting an  insight  into  the  methods  of  a  country  whose  surgery  ranks  among 
the  best,  is  not  to  be  disdained  by  any  one. 

The  Chapters  on: 

a.  The  Head; 

b.  The  Chest; 

c.  The  Abdomen,  are  particularly  well  written. 

d.  The  Surgery  of  the  Gastro-Intestinal  Tract  is  really  dealt  with  in  a 
remarkable  fashion,  even  if,  on  a  few  points,  the  author's  opinion  diflfers 
from  that  of  most  American  authorities.  This  section  represents  the 
views  of  Billroth  and  Pels-Leusden. 

e.  The  technique  is  based  on  Fedor  Krause's  technique,  particularly 
in  trigeminal  neuralgia. 

f.  Sauerbruch's  and  Brauer's  doctrines  are  adhered  to. 

g.  The  wealth  of  Illustrations  is  one  of  the  strong  features  of  the 
book.  There  are  668  of  them.  The  drawings  are  clear  and  simple,  and 
bring  out  strongly  the  particular  details  which  the  author  has  set  himself 
the  task  to  illustrate. 

h.  The  price  is  most  reasonable  and  within  the  reach  of  everybody — 
only  $7.00. 

i.  The  typographical  part  of  the  book  should  recommend  it  to  every 
one.  The  type  is  easy  to  read  and  does  not  tire  the  eye.  The  book  con- 
tains 757  pages. 

k.  This  is  THE  book  the  profession  has  been  looking  for  with 
eagerness  for  quite  a  while. 

F.  J.  REBMAN. 
New  York. 


TABLE   OF   CONTENTS 

CHAPTER 

I.  Antisepsis,  Asepsis. 
II.  Anesthesia — local,  14;  lumbar,  24;  general,  28. 

III.  Skin — division  and  suture  of,  49. 

IV.  Bloodvessels— surgery  of:  (a)  general,  86;  (6)  special,  100. 

V.  Extremities — surgery  of,  137;  amputations:    (a)  in  general,  142; 

(6)  in  particular,  142;  (c)  of  lower  extremities,  156;  Resections, 
187;  Various  operations,  216. 

VI.  //earf— operations  on :  (a)  skull,  243;  (h)  face,  279. 

VII.  Neck — operations  on :  (a)  pharynx,  339;  (b)  nerves,  369. 

VIII.  iBreasf— operations  on :  (a)  mamma,  374;  (6)  ribs,  380;  (c)  sternum, 
888;  (cZ)  heart,  390;  (e)  pleura,  402. 

IX.  Abdomen— (a)  walls  of,  433;  (6)  stomach.  490;  (c)  intestines,  540; 
(d)  anus  and  rectum,  577;  (e)  liver  and  bile  ducts,  608; 
(J')  pancreas,  628. 
X.  Urinary  and  Sexual  Organs— (a)  urethra.,  633;  (b)  bladder.  655; 
(c)  kidneys,  667;  (rf)  penis,  695;  (e)  scrotum,  703;  (/)  prostate, 
711;  (g)  seminal  vesicles,  718. 


^I^rb^r  jFOrtll  P^^s-Leusden :  Surgical  Opc-ations    ^^ 

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Please  send  me  by Express  (or  mail)  one  copy  of 

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SURGICAL  OPERATIONS 

A    HANDBOOK   FOR   STUDENTS  AND   PRACTITIONERS 

By  Prof.   FRIEDRICH    PELS-LEUSDEN,   Berlin 
Translated  by  Dr.   FAXTON    E.    GARDNER,   New  York 

With  668  Illustrations.     758  pages Cloth,  $7.00 

REBMAN    COMPANY  New  York  City 


EXTRACTS    FROM    REVIEWS. 

Prof.  Pels-Leusden  has  written  here  a  very  satisfactory  work-  dealing  largely  with  present- 
day  German  surgical  practice,  and  the  completeness  of  the  same  is  well  shown  from  the  study 
of  any  one  chapter  taken  at  random,  such  as  that  on  anesthesia  in  the  first  part  of  the  book,  in 
which  we  are  furnished  with  a  detailed  resume  of  a  great  many  more  methods  than  are  con- 
tained in  the  average  surgical  text-book.  The  same  may  be  said  of  the  rest  of  the  book's 
contents. — Medical  Record. 

The  volume  before  us  is  from  the  pen  of  the  chief  of  the  surgical  dispensary  of  the  Charite 
Hospital  in  Berlin,  a  pupil  of  Konig's,  who  has  grown  up  in  the  traditions  of  the  school  of  v. 
Langenbeck  and  v.  Bergmann.  He  presents  a  good  exposition  of  the  classical  operative  proced- 
ures, and  makes  his  book  especially  valuable  to  the  student  by  the  detailed  consideration  of  the 
simpler  maneuvers,  such  as,  for  instance,  catheterization.  Abundant  and  clear  diagrammatic 
iiawings  elucidate  the  text.  .  .  .  The  book  is  well  printed  on  good  paper.  It  makes  a  good 
text-book. — California  State  Journal  of  Medicine. 

Written  in  a  careful,  painstaking  manner,  with  close  attention  to  detail,  it  makes  an  ideal 
text-book  for  the  student,  particular  in  his  operative  surgical  courses,  and  for  the  junior  prac- 
titioner. Particular  attention  has  been  paid  by  the  author  to  the  description  of  the  technic  of 
the  more  common  operations,  those  that  would  be  most  apt  to  fall  to  the  lot  of  the  man  in 
General  Practice,  although  the  specialist  will  find  many  points  worthy  his  close  consideration. 
.  .  .  The  translation  has  been  most  excellently  done.  The  illustrations,  mostly  in  the  form  of 
diagrammatic  representation  of  points  in  technic,  are  very  clear.  Altogether  it  makes  a  most  reli- 
able text-book,  one  that  can  be  cordially  recommended  to  the  profession. — Chicago  Medical 
Recorder. 

This  is  an  interesting  volume  ....  the  chapter  on  Surgery  of  the  Bloodvessels  is  exception- 
ally good,  and  we  are  tempted  to  say  the  best  we  have  seen  by  any  author.  The  book  is  well 
written,  and  we  can  candidly  say  that  it  is  a  distinct  addition  to  surgical  literature. — Indianapolis 
Medical  Journal. 

The  description^"  are  clear  and  concise.  The  volume  is  a  valuable  one  and  will  prove  of 
decided  interest  to -the  student,  to  the  surgeon,  and  to  the  general  practitioner. — Yale  Medical 
Journal. 

This  book  is  neither  too  elementary  for  the  practitioner  nor  too  advanced  for  the  student, 
but  is  a  practical  treatise  on  general  surgery  taken  largely  from  the  author's  rich  experience. — • 
New  England  Medical  Gazette. 

The  work,  both  in  its  execution  and  in  the  temperament  of  the  author,  is  essentially  prac- 
tical, thus  conforming  rather  to  American  than  to  German  standards. — Buffalo  Medical  Journal. 

This  is  a  most  excellent  handbook  for  the  use  of  students  and  general  practitioners.  What 
•tommends  itself  most  particularly  to  the  reader  is  the  excellent  character  of  the  numerous  dia- 
grams and  illustrations,  as  well  as  the  clearness  and  succinctness  of  the  text.  We  can  con- 
scientiously recommend  it  as  a  trustworthy  guide. — Nashville  Journal  of  Medicine  and  Surgery. 

A  particularly  attractive  feature  of  the  work  is  the  arrangement  of  the  various  systems  into 
groups.  Most  text-books  take  up  the  several  operations  as  though  they  were  entirely  separate 
procedures,  whereas  this  book,  instead  of  discussing  the  several  operations  on  the  extremities  in 
groups  by  themselves,  takes  up  in  the  same  section  the  operations  done  on  this  portion  of  the 
body.  This  method  has  the  advantage  that  with  as  little  expenditure  of  energy  as  possible  the 
student  is  immediately  made  aware  of  what  surgical  procedures  are  applicable  to  the  portion  of 
the  body  under  discussion.  The  illustrations,  though  diagrammatic,  are  exceptionally  clear  and 
illustrate  the  matter  in  hand  excellently.  Taken  in  all,  Professor  Pels-Leusden  has  produced  a 
book  ideally  adapted  to  student  purposes. — Maryland  Medical  Journal.  3 

The  Rebman  Company  is  doing  a  valuable  piece  of  work  in  furnishing  translations  of  im- 
portant foreign  medical  books,  and  "Surgical  Operations"  is  one  of  the  best  of  its  series.  .  .  . 
It  is  a  well  illustrated  work  of  about  700  pages,  with  good  type  and  paper. — Johns  Hopkins 
Hospital  Bulletin. 

7-8-13— 2000— M-B. 


SUUGKRY 

OK     11  IK 

BRAIN  AND  SPINAL  CORD 

BASED    ON    PERSONAL    EXPERIENCES 

in' 
PROF.   FEDOR    KRAUSE,   M.D. 

CKII.     MKDIZINM.IIAT 
Dllill.lKHK.NDr.U    AHZT    AM     AIGISTA     iroSIMTAL    VX    HKIILIN 

ENGLISH    ADAFFATION    BY 

DR.   xMAX   THOREK   (Rush  M.  C.  Univ.  of  Chicago) 

suiu;kon-Ii\-(iiii;i-  amk.iik  ax  hospital,  ciiicaoo.  ill.  :  consiltant 
cook  couxtv  hospital,  chicago,  ill.  ;  e.\-pi(oi--essoh  op 

SUIlGEnV.   HKX.NET   MEDlrAL  COLLF,(;E  (pRES.   LOYOLA 
IMXKllSITv).    CIlUAfiO.     ETC.,    ETC. 

VOLUMES   11   AND   111 


WITH  Ul  FIGURES   IN   THE   TEXT.    -U;   COLORED    PLATES,    AND 
ONE  HALF-TONE   PLATE 


J>   Us  'Si 


N  1-:  W      V  ()  l{  K 
R  E  B  M  A  N     C  ()  .M  P  .V  N  Y 

11  ij;)    UllO.A  1)\\  AV 


PUBLISHERS'    ANNOUNCEMENT 

The  author  says  in  his  Preface  that  the  immense  amount  of  material  placed 
at  his  disposal,  by  neurologists  and  surgeons  the  world  over,  has  made  it  possible 
for  him  to  give  in  this  work  the  most  thorough  and  complete  review  of  the  pres- 
ent state  of  the  Surgery  of  the  Brain  and  Spinal  Cord,  including  Diagnosis. 
Theoretical  questions  about  which  no  new  developments  have  been  recorded  are 
not  discussed,  but  the  reader  is  referred  to  the  many  monographs  (by  t>.  Berg- 
mann,  Kocher,  etc.)  that  have  appeared  on  the  subject.  He  does  so  in  order  to 
avoid  needless  repetition.  But  he  has  deemed  it  necessary  to  add  important  Clin- 
ical Observations  in  extenso,  as  characteristic  examples. 

The  work  interests  all  Surgeons  in  general,  but  particularly  the  Nerve  Spe- 
cialists, Eye,  Ear,  Nose  and  Throat  men,  and  the  Syphilologists.  This  makes  the 
field  of  interest  very  extensive. 

It  is  not  a  text-book,  but  is  intended,  with  the  aid  of  the  incomparably  beau- 
tiful illustrations,  to  offer  a  thorough  survey  of  the  present  position  taken  by 
Brain  and  Nerve  Surgery.    The  technic  is  thorough  and  up  to  date. 

Volume  I  deals  with  Trephining,  Cysts,  Tumors,  Cerebral  Wounds,  Cerebral 
Puncture,  Centricular  Puncture,  Lumbar  Puncture,  Use  and  Application  of  the 
X-Ray;  all  pass  before  the  reader  in  a  grand  review,  but  in  simple,  instructive 
language. 

See  the  Ear  cases  on  pp.  107-150,  etc.;  Chloroform  versus  Ether,  p.  156; 
Asepsis,  p.  159;  Care  of  Hands,  Towels,  Antiseptics,  p.  159;  Use  of  Bare  Hand, 
p.  160;  Face-Mask,  Dressing,  etc.,  p.  160. 

It  deals  with  the  mor.e  general  sections  of  the  Brain  Surgery  and  contains  24 
Colored  Plates  with  48  Figures,  one  Photo  Print  with  5  Figures,  and  63  Figures 
illuminating  the  text.  $6.00.     Bound  in  Art  Leather. 

The  Second  Volume  deals  with  Epilepsy,  Neoplasmata  of  the  Brain,  the 
Frontal  Brain,  the  Central  Region,  the  Temporal  Lobe  and  the  Region  of  the 
Island  of  Reil.  It  also  deals  with  Neoplasmata  of  the  Parietal  Lobe,  the  Occipital 
Brain,  and  the  Posterior  Fossa  of  the  Skull.  Then  it  takes  up  Syrrjptomatology 
and  Neoplasmata  at  the  Base  of  the  Brain  and  in  the  Contiguous  Regions.  It  con- 
tains 27  Colored  Figures  and  4  Half  Tones  on  15  Plates,  and  94  Figures  in  the 
Text,   14  of  which  are  in  colors.     Price,  $7.00.     Bound  in  Art  Leather. 

Volume  III  contains  the  concluding  chapters  of  the  Surgery  of  the  Brain, 
i.e.,  Neoplasmata  of  the  Base  of  the  Brain;  Prognosis  in  the  Extirpation  of  Cere- 
bral Tumors ;  Intracranial  Suppuration ;  Metastatic  Processes  and  Cerebral  In- 
juries.    The  rest  is  devoted  to  the  Surgery  of  the  Spinal  Cord. 

It  contains  47  Figures  on  22  Plates  and  42  Figures  in  the  Text,  3  of  which 
are  colored.    Price,  $7.00.     Bound  in  Art  Leather. 

We  point  with  particular  pride  to  the  many  illustrations  in  the  text  and  to 
the  colored  plates,  which  are  printed  on  coated  paper.  The  work  is  now  com= 
plete  and  contains  122  Colored  Figures  on  60  Plates;  9  Half  Tones  on  2 
Plates;  and  199  Illustrations  in  the  Text,  17  of  which  are  colored. 

3  VOLS.     ART  LEATHER,  $20.00.     Sold  by  Subscription  only. 

REBMAN    COMPANY. 

1 123  Broadway,  New  York. 


Table  of  Contents  of  Volume  II 


A.  BRAIN 


EPILEPSY 

INTHODLC  rOlJY    U1",MAKKS  ON    I'l  I^'SIOLOCV 

Electric  Irritation      ..... 

Sherrington-Grneuhiiiim  lii\  istifjations 

Hilsig's  Discovery     ..... 

My  Methods 

Galvanic  Invitation    ..... 
Unipolar  Faradic   Irritation  .... 

Induction  Apparatus  .... 

Strength  of  Current  ..... 

Electrode  ...... 

Scarification  of  the  (Edi-niatous  Arachnoidea 

My  Own  Table  of  Foci      .... 

Non-irritable  Intermediate  Areas 

Results  of  Irritation  in  Tumors  . 
Results  of  Irritation  on  the  Brains  of  Epileptics 

Dangers  of   Irritation  .... 

ANATOMIC    PROOFS    FOR    THE    EXCLUSIVE    IRRITABILITY 
OF  THE  ANTERIOR  CENTRAL  CONVOLLTION 
Macroscopic  Findings   ..... 

Observation  I,   1         . 

Observation  I,  2        . 

Observation  I,  3        . 

Excised  Cortical  Ciliom.i  of  the  Anterior  Ciiitral  Convolution 
Microscopic  Findings    ..... 

Investigations  of  Brodmanii  .iiid  N  ogt 

Jacksonian  Epilepsy 

Course  of  Spasms        ..... 
The  Primary  Spasming  Ciiitre        .  . 

Difference  between  Tonic  and  Clonic  Spasms 
Sensory  Form  of  Jacksonian  Epilepsy 
ETIOLOCY  OF  JACKSONIAN   EPILEPSY    . 
Intoxications,   Infections    .... 
RcHcx   Action  as  a  C.ius.-  of  .I.ickM.ni.iii   I'pilepsy 


Table  of  Contents 


TUMORS  AS  A  CAUSE 

Observation  I,  4         . 

Sensory  Jacksonian  Manifestations 

Observation  I,  5        . 
INFANTILE  PARALYSIS  AS  A  CAUSE 

Acute  Encephalitis  .... 
Pathogenesis  of  Jacksonian  Epilepsy 

Observation  I,  6        . 

Predisposition  to  Epilepsy 

Recurrent  and  Bilateral  Encephalitis  . 

Observation  I,  7 
Etiologic  Factors 

Lues 
Anatomic  Changes 

CEdema  of  the  Arachnoid 

Cicatricial  Processes 

Cysts 

Sclerosis  of  the  Brain 

Mycrogyrism     . 
Focal  Symptoms  in  Cerebral  Infantile  Paralysis 
Operative  Intervention 

Time  of  Operation    . 

Point  of  Attack 

Operation  in  Two  Stages 

Uncertainty  of  Cranio-cerebral  Methods 

Uncertainty  in  Locating  Cerebral  Convolutions 

Faradic  Localization  and  Excision  of   the  Primary  Spasming  Centre 

Puncture  of  Corpus  Callosum  and  Drainage  of  Ventricle 

Observation  I,  8        . 

Multiple  Cortical  Cysts      .... 

Observation  I,  9        • 
Porencephalitis    ...... 

In  the  Area  of  the  Central  Region 

Observation  I,   10      . 
Porencephalitic  Cysts  Beyond  the  Central  Region 

Observation  I,   11      . 
INJURIES  AT  BIRTH 

Breech  Presentation  .  .  .  .     • 

Observation  I,   12      . 

Forceps  Delivery       .  .  .  .  . 

Observation  I,   13      . 
Identity  of  Changes    in    Infectious   and   Traumatic   Encephalitis   of 
Children        . 

Observation  I,   14 


Table  of  Contknin 


JACKSONIAN  EPILEPSY  WITHOUT  ANATOMK    IINDINCiS 

Excision  of  the  Priiimry  Spasming  C'cntri 

Tt'chnic  ..... 

Theoretic  Consiilcr.itiims     . 

FiivorahK'  Effn-ts  upon  M()rlii<l  I'lu-i    Deeply  Sitii;iti-(1  in  the  Hniii 

Observation  I,    l;j      . 
RESULTS  OF  CORTICAL  EXCISU)NS 
Distui-bances    of  Motility  and  Sensihiiit 

General    ..... 

Observation  I,  15      . 

Motility  .... 

Contracture.s  and  Rigidities 

Electric  Irritability  of  Muscles  . 

Reflex  Irritability 

Sensation  of  Touch   . 

Temperature  Sense    . 

Sense  of  Position 

Trophic  Disturbances 

Observation  I,    10      . 

Mobility  .... 

Rigidities  .... 

Reflexes  .... 

Sense  of  Touch  and  Stereognostic 

Temperature  Sense    . 

Sense  of  Position 
Disturbances  of  Aphasia  and  Agraphia 

Motor  Aphasia 

Brocas  Centre  .... 

Example  for  Word-dumbness 

Wernicke's  Centre     . 

Word-deafness 

Pierre-Maries  Hypothesis  . 

Diaschisis  Action 

Agraphia  .... 

Observation  I,   ifi      . 

Observation  I.    17       • 

General  Genuine  Epilepsy 

Relation  to  the  Jacksonian  .\ttacks 
Rise  of  Pressure  During  the  Attack 
Observation  I,   IS      . 
Experimental    .... 
Kocher's  \'alve  Formation 
Uncertainty  of  Indications 


Table  of  Contents 


Safety  of  Valve  Formation 
Technic  of  Valve  Formation 


Results  Obtained  from  Operations  for  Epilepsy 

Question  Sheet         ...... 

General  Genuine  Epilepsy  .... 

Remaining  Pareses    ...... 

Jacksonian  Attacks    ...... 

Eventual  Exposition  of  the  Other  Central  Region 
Cures        ........ 

Im^provement  of  the  Intellectual  Powers  and  ]SIemory 
Valve  Formation        ...... 

Persisting  Paralysis  after  Excision  of  Centres 
Improvement  of  Contractures  and  Paralysis  in  Infant 
Paralysis  ....... 

Aggravation  of  Attacks  by  the  Operation    . 

INDICATIONS  FOR  OPERATION 
General  Genuine  Epilepsy     . 

Improvements  . 

Statistics 
Jacksonian  Epilepsy 

Time  for  Operation  . 

Proper  Cases  for  Operation 

Safety  of  Operation  . 

Methods  of  Procedure 

COURSE  AFTER  THE  OPERATION 
Status  Epilepticus  and  Coma 
Period  of  Freedom  after  Operations 
After-treatment   .... 


Traumatic  and  Reflex  Epilepsy 

Injuries  of  the  Central  Region 

Observation  I,  19      • 

Exciting  Cause,  Predisposition  . 

Aura         ..... 

Anatomic  Changes     . 

Traumatic  Brain  Cysts 

Injuries  of  the  Brain  through  Contre-* 
Other  Cerebral  Injuries 

Frontal  Brain   .... 

Observation  I,  20      . 

Chronic  Suppurative  Processes  of  the 
Indications  for  Operation 

Relation  to  Osseous  Defects 


Cranial  Bones 


le  Cerebral 


Table  of  Contents 


REFLEX  EPILEPSY 

Post-opcnitivc  Epilcpsj'      .... 

()l)s(rvati<)ii  I,  'JI       . 

NEOPLASMATA   OF  THE   BRAIN 
General  Symptoms  of  Cerebral  Pressure 

Gradually  Increasing  Diiiiimiliuii  i>f  Sp.ici-  . 
Hi'adaches  . 

Nausea,  Vomiting 
Psychic-  Disturbances    . 

Stupefaction 

General  Spasms 

Sense  of  Dizziness     . 
Choked  Disc 

Shifting  of  Color  Outlines  in  the  \'isual  Field 

Slow  Pulse        ...... 

Paralysis  of  the  Respiratory  Centre     . 

Introduction  to  Focal  Symptomatology  of  Neoplasmata  of 
the  Brain 

Local  Symptoms  of  Bones  of  Skull 

Pain;  Bruit  du  pot  fele;   Tympanic  Resonance     . 

Silent  Cerebral   Territories  .... 

Right-handedness,  Left-handedness    . 
Neighborhood  Symptoms  ..... 

SCHEME  OF  LOCALIZATION  IN  THE  CEREBRUM 
Focal  Symptoms        ...... 

Kocher's  and  Kronlein's  Constructions 

Position  of  Brain  in  Skull  .... 

Scheme  of  Localization  on  the  Conve.v  Surface     . 
Scheme  of  Localization  on  the  Median  Surface    . 

NEOPLASMATA  OF  THE  FRONTAL  BRAIN 

Position  of  the  Frontal  Lobe       ..... 
Extended  Operative  Possibilities         .... 

Use  of  Suction   in   the    Removal    of    Cerebral   Neoplas 


mata.    Suppl 

Observation  11.    1 

Symptomatology 

Psyihic  Disturbances 
Witz.-Kucht 
Observation  11,  2 


nieiit   tu  thi 


Tc 


hnie 


Table  of  Contents 


Cerebral  or  Frontal  Ataxia    .... 

Differential  Diagnosis  from  Cerebellar  Ataxia 

Observation  II,  3      . 
Rotation  of  the  Head  and  Eyes 

Deviation  Conjugee  . 

Tonic  Spasms  of  Muscles  . 
Neighborhood  Symptoms 

Disturbances  of  Smell;  Participation  of  the  Optic  Nerves,  the 
Nerves  of  the  Ocular  Muscles  and  the  Anterior  Central 
Convolution        ....... 

NEOPLASMATA  OF  THE  CENTRAL  REGION 

Position  of  the  Central  Convolutions 

Symptomatology 

Unilateral  and  Bilateral  Innervation  from  the  Cerebral  Cortex 
Motor  Symptoms  of  Irritation  and  Paralyses    . 

Cortical  Neoplasmata  .... 

Observation  III,   1     . 

Monoplegia  Facialis,  Brachialis,  Cruralis     . 

Observation  III,  2     . 

Observation  III,  3    . 

Observation  III,  4    . 
Sensory  Disturbances  of  Irritation  and  Paralyses 

Tactile  Paralysis        ..... 

Astereognosis   ...... 

Tumors  of  the  Posterior  Central  Convolution 

Observation  III,  5    . 
Disturbances  of  Apraxia         .... 

Observation  III,  6     . 
Subcortical  Neoplasmata         .... 

Observation  III,  7     ■ 
Fibres  of  the  Corona  Radiata  and  Internal  Capsule 

Carrefour  Sensitif      .  .  .  ... 

Neighborhood  Symptoms        .... 

Accidents  After  Successful  Extirpation  of  Tumors 

Observation  III,  8     . 

Solitary  Tubercle  and  Gumma    . 
Cyst  Formations  ...... 

Observation  III,  9     ■ 

NEOPLASMATA    OF    THE   TEMPORAL  LOBE    AND 
THE  REGION  OF  THE  ISLAND  OF  REIL 

Position  of  the  Temporal  Lobe  ....... 

Difference  between  Right  and  Left  Hemisphere  .  .  .  . 


Table  of  Coxtknts 


Symptomatology 

Ai)liiisi.i        ..... 

AiiJirtliria.   Dysarthriii 

Motor  and  Sensory  Aphasia 
Psychic  Dcafni'ss  (Acustic  Agnosia) 

Position  of  the  Ishtnd 

Observation  IV,   1      . 

NEOPLASMATA  OF  THE  PARIETAL   LOBE 


.\naloniie  I'osition     . 
Participation  in  the  Central  liimrvatioii  of  Opposit 

Symptomatology 


Alexia  and  .V^raplii.a     . 

Hemianopsia 
Apraxia        ..... 

Kinirsthetic  Recollection  of  Pictures 

Limb-kinetic  Apraxia 

Ideo-kinetic  Apraxia  (Motor  Apraxia  Par  Excellence) 

Ideatory  Apraxia 

Conclusion         .... 
Observation  V,   1      . 

Deficiency  of  Words 

Understanding  of  Speech  . 

Writing  ..... 

Reading,  Translating 

Figuring.  .... 

.\praxia   ..... 

Epicrisis  ..... 

Manifestations  of  Aphasia 

Apraxia  ..... 

Astereognosis  .... 

Cortical  Seat     .... 

Absence  of  Hcnii.moiisia    . 

Dangers  of  Cerebral   Punctures   . 
Optic  .\phasia       .... 

Amnetic  or  N'erbai  .Aphasia 

Deviation  Conjugce  . 

Ol.srrv.ition  \".   -'        . 

NEOPLASMATA  OF  THE  OCCIPITAL   BRAIN 

I'osiliiin  of  th<-  Oceipit.il   Lobes  .... 

Symptomatologfy 

HEMIANOPSIA 

Observation  \'I.   1     . 


Sid 


)f  B( 


lody 


10 


Table  of  Contents 


Brain  Fever,  Hyperthermia 

Hemianopsia  and  Optic  Hallucinations 

Neighborhood    Symptoms     (Alexia,     Agraphia,    Disturbances     of 
Motility  and  Sensibility,  Aphasia) 
Course  of  the  Fibres  in  the  Visual  Tract 

Seat  of  Morbid  Foci  in  Hemianopsia  . 

Quadrant  Hemianopsia 

Difficulties  in  Diagnosis     . 

Observation  VI,  2     . 

Field  for  Optic  Recollections  on  the  Convexity  of  the   Occipital 
Lobe,  Psychic  Blindness     ..... 

Optic  Aphasia  ........ 

Occipital  Centre  for  Movements  of  the  Eyes 

Hemianopic  Disturbances  of  the  Sense  of  Color  . 

Observation  VI,  3     . 
Cortical  Blindness  ....... 

Pupillary  Fibres  ........ 

Hemianopic  Pupillary  Reaction,   Pupillary  Dilatation  . 
Tubular  Vision     ........ 

Observation  VI,  4     ......  . 

Bilateral  Cortical  Projection  of  Macula  Lutea 

Cerebellar  Symptoms  in  Neoplasmata  of  the  Occipital  Brain 

Observation  VI,  5     . 

NEOPLASMATA    IN    THE    POSTERIOR    FOSSA    OF 
THE  SKULL 

Boundaries  and  Contents  of  the  Posterior  Fossa  of  the  Skull 

Bony  and  Fibrous  Walls     . 

Nervous  Elements,  Fourth  Ventricle  . 

Bloodvessels 

Arteriae  Vertebrales 

Sinus 
Introductory  Remarks  on  Physiology 

Pons,  Corpus  Quadri, 
bral  Nerves) 

Cerebellum 

Course  of  Fibres 

Functions 

Symptom-Complexes 

Reflex  Tracts    . 

Resume  of  Personal  Material 

Tumors  of  Cerebello-Pontine  Angle 

Tumors  of  Cerebellar  Substance  and  Vermis 

Neoplasmata  of  the  Pons  and  Ventricular  Walls 


geminum.  Rhomboid 


Fossa 


(Nuclei  of 


Cere 


Taulk  of  Contents 


11 


Fluid  Collections  (Cysts)  .... 

Absci'sses  ...... 

Pscudo-tuinors  ...... 

Metastatic  Tumors     ...... 

SYMPTOMATOLOGY 

GENEH.\L  SYMPTOMS  OF  CEREBRAL  PRESSURE 
Hi-adachi'S        ...... 

Vomiting  ...... 

Choked  Disc  and  Disturbances  of  Vision 
Respirations  and  Pulse        .... 

Stupefaction  and  Other  Psychic  Disturbances 

FOCAL  MANIFESTATIONS. 

VertifTo        ..... 

Ziehen's  \'estibular  .Attacks 
Ataxia  ..... 

Cerebellar  .Vtaxic  (iait 

Asynergie  Cerebelleuse 

Hemiataxia  and  Adiadochokinesis 

Asthenia,  Atonia.  Astasia 
Motor  Manifestations    . 

Eiiileptiform  Spasms 
'         Forced  Position,  Forced  Movements 

Sensory   Disturbances 
Anaesthesia  Para-sthesia 

PARTICIPATION  OF  THE  CEREBRAL  NERVES 
General  Bulbar  Symptoms 
Movements  of  the  Eyes 
Nystagmus 
Abducens 
Facialis 

Nervus  Acusticus 
Ncrvus  Ve.stibularis 
Baranys  Caloric  Nystagmus 
Glossopharyngeus,  ,\ccessorius,  Hypoglossus 
Motor  Branches  of  X'agus  . 
Trigeminus 

Reflex  .Anaesthesia  of  Cornea 
Keratitis  Neuroparalytica 
Changes  of  Intracninial   Pressure  .\fter  First  Sitting 
Operation  in  Two  Stages 
Release    . 
Attempts  to  Complete  Release  of  Pressure  .\fter  First  Step  . 


12 


Table  of  Contents 


of   Hydro- 


Respiratory  Paralysis  .  .  .  .         ■ . 

Puncture  of  Corpus  Callosum      ..... 

CYSTS  IN  THE  POSTERIOR  FOSSA  OF  THE  SKULL 
Traumatic  Cysts  .... 

Observation  VII,  1   . 

Traumatic  Cyst  of  the  Vermis    . 

Observation  VII,  2    . 

Post-operative  Cyst  Formation  . 
Arachnoideal  Cysts        .... 

Observation  VII,  3   . 

Arachnoideal  Cystems 
True  Glia  Cysts  of  the  Cerebellum 

Observation  VII,  4   . 
Cysts  of  the    Cerebellum    as    an    Association  Symptom 
cephalus        ..... 

Intemus  of  All  Ventricles 

Extroversion  of  the  Fourth  Ventricle  . 

Tumor  Cysts     ..... 

Observation  VII,  5   . 

Suspicion  of  Neoplasm  or  Other  Processes 

SOLID  TUMORS  OF  THE  POSTERIOR  FOSSA  OF  THE  SKULL 
Tumors  of  the  Cerebello-pontine  Angle  (Neuroma  of  Acusticus) 
Development  of  Technic   ........ 

Observation   VII,    6.       Intracranial    Exposure    and    Resection   of    the 
Nervus  Acusticus        ........ 

Application  of  Suction       ........ 

Observation  VII,  7 

Epicrisis,    Resume  of  Symptoms  of    Neoplasmata   at    Cerebello- 
pontine Angle  .  .  .  .  .  .  .  ... 

Observation  VII,  8 

Impossibility  of  Radical  Extirpation       ...... 

Observation  VII,  9   •■■■■•-.  . 

Sarcoma  of  Arachnoid  ......... 

Observation  VII,   10 

Tumors  of  the  Region  of  the  Vermis  and  Cerebellar  Substance 

Tumors  of  Hemispheres     ........ 

Cystic  Tumors .......... 

Solid  Tumors :   Sarcomata,  Angiosarcomata,  Goliosarcomata,  Fibro- 
sarcomata,  Vermis  Tumors .  .  .  .  .  . 

Observation  VII,  11  ........ 

Wide  Opening  of  IVth  Ventricle  .  .  .  .  . 

Observation  VII,   12 

Opening  of  Aquseductus  Cerebri  (Sylvii)    .          .          .          .          . 
Observation  VII,  13 


Tabi,k.  ok  Contents 


18 


Solitnry  TulxTclc  of  C'cnhillimi 

Diiijfiiosis 

Observation 

Secondary  Hyilroccpli.ilus  . 
Ciuiiini.ita     .... 

NEOPLASMATA    AT    THE    BASE    OF    THE    BRAIN 
AND   IN  THE  CONTIGUOUS   REGIONS 

Okservation  VIII.   1 

Cholesteatoma  ....... 

Tumors  of  the  Hypophysis    ..... 

Aeromegaly.  Bitemporal   Hemianopsia 

Observation  VIII,  2 

Operation  from  Above        ..... 

Observation  VIII,  .'J 

Endonasal  Operation  of  0.  Ilirxch 
Tumors  Originating  on  Inner  Surface  of  Dura 

Observaticm  VIII,  4 
Cysticercus  Racemosus;  Basal  Cysticercus  Meningitis 

Observation  \'III,  5 

Operations  on  the  Brainstem  and  in  its  Vicinity 

Exposure  of  Medulla  Oblongata 
Exposure  of  Pons  Varolii 
Corpus  Quadrigeminum  and  \'icinity 
Puncture  of  Corpus  Callosum 
Observation  VIII,  6 


Table  of  Contents  of  Volume  III 


NEOPLASMATA  OF  THE  BASE  OF  THE  BRAIN 

Resemblance  to  Tumors  of  Brain         ..... 
Tumors  of  Posterior  Surface  of  Petrous  Portion  of  Temporal  Bone 
Kyphosis  of  Base  of  Skull 
Timiors  of  Middle  Fossa  of  Skull 

Tumors  of  Gasser's  Ganglion   . 

Extirpation  of  Ganglion  Gasseri     . 

Ligation  of  Trunk  of  A.  Meningea  Media 
Tumor  of  Gasserian  Ganglion 

Observation  IX,   1     . 

PROGNOSIS  IN  THE  EXTIRPATION  OF  CEREBRAL 
TUMORS 


Dangers  of  the  Operation 
Septic  Meningitis 
Pneumonia 

Elevation  of  Temperature 
Cerebral  Softening    . 
Misleading  Internal  Therapy 
Tumors  Not  to  be  Operated  on 
Seat  of  Neoplasm 
Statistics 


INTRACRANIAL  SUPPURATIONS 
Traumatic  Cerebral  Abscesses 

Acute  Traumatic  Brain  Abscess 

Observation  X,  1       . 

Observation  X,  2       . 
Chronic  Abscesses  of  Traumatic  Origin 

Diagnosis  ..... 

Indications  for  Trepanation 

Abscesses  Due  to  Other  Causes  . 
Extradural  Traumatic  Abscesses 

Observation  X,  3       . 

14 


Table  of  Contknts 


15 


Otitic  Cerebral  Abscesses 

Operative  Teehiiie     . 
Temi)onil  Lobe  Abscesses 

Observation  X,    l-       . 
Multiple  Abscesses  of  Ti-Tiiporal  Lol)e 

Observation  X,  5       . 
Cerebellar  Al)scess 

Observation  X,  6        . 
Extradin-al  Abscesses  (Otitic) 

Observation  X,  T       . 
MENINGITIS  SEROSA  EX  OTITIDE 

Observation  X,  8       . 
Cyst  Formation  in  Brain  in  Connection  with  Otitis  Medi 

Observation  X.  9       . 
THROMBOPHLEBITIS 

Septic  Thrombosis  of  Sinus  Sigmoideus  and  ^ 

Observation  X.    10     . 
Bland  Thromlioses 

Observation  X.   1 1      . 
Infectious  Thrombosis  in  Other  IiiHammatory  Processes  and  Su] 
tions  .... 

Observation  X.   12    . 
Rhinitic  Abscesses 

Observation  X.   13    . 
Meningitis  Purulenta    . 

Trephining  for  Treatment 

Circumscribed  Purulent  Meningitis 

Diffuse  Purulent  Meningitis 

Observation  X,   14     . 

METASTATIC   PROCESSES     . 
Metastatic  Carcinoma  of  Brain 

Observation  XI.    1      . 
Operation  on  Metastatic  Br.iin  Tumors 

Observation  XI,  'J 
Metastasis  Throughout  Body 
Observation  XI.  .'J 
Actinomycosis  . 
METASTATIC  CARCINOM.V  OF  THE  1)L"R 
Oliservation  XI.    t     . 

Metastatic  Brain  Abscesses 

Statistics 
Oliservation  XI,  5 


16  Table  of  Contents 


Operation  on  Metastatic  Brain  Abscesses  ..... 

Observation  XI,  6     ........  • 

Frequence  of  Cerebral  Embolism  Following  Suppurative  Processes 
in  the  Lung      ......... 

Attempt  at  Explanation     ........ 

Solitary  Metastatic  Abscesses  ....... 

CEREBRAL  INJURIES 

Cerebral  Concussion,  Commotio  Cerebri  ..... 

Cerebral  Contusion,  Contusio  Cerebri      ...... 

Cerebral  Pressure,  Compressio  Cerebri  ..... 

Treatment  of  Cerebral  Concussion  and  Cerebral  Bruising 

Treatment  of  Wounds  of  the  Brain     .  ... 

Observation  XII,   1    ........  . 

Observation  XII,  2   ........  . 

Probing  of  Cerebral  Wounds       ....... 

Incised  and  Gunshot  Wounds  ....... 

Wandering  Bullets  in  the  Brain     ....... 

Observation  XII,  3 

Healed  Blade  of  Knife      ........ 

Observation  XII,  4   ........  . 

Treatment  of  Intracranial  Hemorrhage  ...... 

Interval   ........... 

Intradural  Hemorrhages     ........ 

Extradural  Hemorrhages    ........ 

Ligation  of  Trunk  of  A.  Meningea  Media  ..... 

B.  SPINAL  CORD 

Introduction     .......... 

OPENING  OF   VERTEBRAL    CANAL  BY    LAMINEC- 
TOMY  

Preparations,  Dressings,  Course 

POSITION  OF  PATIENT 

Narcosis  and  Local  Anaesthesia       ....... 

Asepsis  and  Dressing  ........ 

Time  of  Healing  ......... 

Laminectomy 

Topographic  Considerations  on  Spinous  Processes 

Incision  into  Soft  Parts      ........ 

Removal  of  Vertebral  Arches      ....... 

Use  of  Chisel   .......... 


Table  of  Contents 


17 


LfiiDincctoiiu'    ...... 

Removal  of  a  Nmiil)LT  of  .\rrlic-s  in  One  I'k-et 

Horsley's  Cutting  Forceps 

Rongeur  Forceps        .... 

Repeated  ()i>erati()ns 
Relation  to  Dura  .... 

Liquor  Tension,   Pulsations 
Extradural  Probing        .... 

Exposure  of  Anterior  Surface  of  Cord  and  Posterior  Surface  of  Ver- 
tebral Bodit's     .... 
Intradural  Probing         .... 

Suture  of  Dura  Mater  and  Muscle  Wound 

Flow  of   Liquor  .... 

Sick's  Procedure        .... 

Operation  in  One  Sitting  . 

Operation  in  Two  Sittings 


NEOPLASMATA    OF 
CORD  . 


THE    MEMBRANES    OF    THE 


Diagnosis  of  Intravertebral  Tumors 

Resume  of  Symjjtoms 
Root  Symptoms    .... 

Compression  of  Cord 
St/mplomx  of  Irritation  of  Spinal  Roots 
Parsesthesias  .... 

Pain 

Hypertrsthesias  of  Certain  Skin   Regions 

Irritation  of  Motor  Roots,  Spasmodic  Contractions 

Anaesthesias  and  Paralyses 
Interruption  of  Conduction  in  the  Cord  Itself 

Brown-Siquard's  Unilateral  Lesions 

Transverse  Lesions 

Paralysis  of  Ahdominal  and  hiteslimil  Miisciiliilia 

Skin  liefle.res 

Bladder,  Rectum,  Trophic  Disturbances 

SYMPTOMS  REFERABLE  TO  VERTEBR.E   PROPER 
Pain  and  Deformities 
Percussion  Sound 
Roentgen  Picture 
Resume  of   Diagnosis 
Duration  and  Cause 
Causes 
Differentiid  Diagnosis 


18 


Table  of  Contents 


Diagnosis  of  Level  of  the  Neoplasm 

Root  and  Segment  Symptoms  ....... 

Function  of   Roots  and  their  Respective  Segments  .... 

SensoTT/  Root-Jields  ......... 

Sherrington's  Law      ......... 

Segment  Innervation  of  the  Muscles  ...... 

Disturbances  in  Eliciting  Reflexes     ....... 

Ascertaining  of  Upper  Limit  ....... 

Relation  of  Segments  to  Vertebrae       ...... 

RELATION  OF  SPINOUS  PROCESSES  TO  SPINAL  SEGMENTS 

Observation  XIII,   1 

Brotvn-Sequard's  Paralysis  ........ 

Diagnosis  .  -  .  .  .  .  . 

Observation  XIII,  2 

Epicrisis ........... 

Observation  XIII,  3 

Epicrisis .  .  .  .  .  .  .  . 

Observation  XIII,  4  ........ 

Cauda  Equina 

Observation  XIII,  5  ........ 

Epicrisis  and  Observations  on  Differential  Diagnosis    . 
Observation  XIII,.  6  ........ 

Epicrisis ........... 

Multiple  Intravertebral  Tumors 

MENINGITIS  SEROSA  CHRONICA   CIRCUMSCRIPTA 

Introduction     ..... 

Arachnitis  Adhaesiva  Circumscripta 

Anatomic  Considerations    . 
Observation  XIV,   1 
Observation  XIV,  2 

Extradural  Processes  as  a  Cause 

INFLAMMATORY   PROCESSES     . 

Observation  XIV,  3 

Observation  XIV,  4 
EXTRADURAL  TUMOR  FORMATION  AS  A  CAUSE 

Observation  XIV,  5  ..... 

Intradural  Inflammatory  Processes  as  a  Cause 

INFLAMMATION  OF  ONE  SENSORY  ROOT       . 
Observation  XIV,  6  ..... 


Table  of  Contents 


19 


ACCUMULATION  OV  LK^LOR   IN   INTRADLRAI.  Tl'MORS 
Obsi-rvation  XIV,  7  .... 

Mfiiiiijiitis  Serosa  Chronica  Circuniscripta  . 

Diagnosis  of  Meningitis  Serosa  Chronica 

Oliscrv.itioii  Xl\',   S 
Trauma  as  a  Cause 

PuiK'turf  of  Dural  Sac 
Etiologic  Factors 
Treatment  ..... 

Observation  XIV,  t) 

Meningo-myelitis  of  Thoracic  Cord 

Epicrisis.  .... 

MENINGITIS  SEROSA  ACUTA  CIRCUMSCRIPTA 

Observation  XH',    10 

Suppurating    Necrotic     Process    on    Arch    of    the    Fifth    Cervical 
Vertebra   ......... 

Epicrisis  .......... 

INDURATIONS  OF  THE  SPINAL    CORD    (MENINGI 
TIS   FIBROSA   CHRONICA) 

Pachymeningitis  Cervical  is  Hypertrophica  . 

Anatomic  Relations  of  Indurations  in  the  Dorsal  Part 

Observation  X\',   1,  with  Autopsy   Findings 

Etiologic  Factors 

Treatment  of  .Meningitis  Fibrosa 

Prognosis  .... 

Observation  XV,  '■2    . 

Observation  XV,  :i    . 

Oliservation  X\'.    1-    . 

INTRAMEDULLARY  NEOPLASMATA 

Observation  X\'l.    1 

Successful  Extirjjation  of  an  Intramedullary  Solitary  Tubercle 
Angioma  Venosum  Racemosum  of  the  Pia  and  Arachnoid 
Solitary  Tubercle  and  (innini.ita  .... 

Observation  X\'l,  '2  ...... 

COURSE   AFTER   LAMINECTOMY 
Disturbances  in  the  Flow  of  the  Liquor  Cerebro-spinalis 
Return  of  Disturbed  Functions         ..... 

Bladder  and  Rectum,   Decubitus     ...... 

Si-nsory  and  Motor  Disturbances  ..... 

Return  of  liroun-Si ifiKird' s  .Symptom  ('om|)lexus  . 


20 


Table  of  Contents 


Other  Untoward  Manifestations 

Observation  XVII,  1  ........ 

Seat  of  Tumor  on  the  Anterior  Surface  of  the  Cord 
Return  of  Movements  ......... 

Observation  XVII,  2 

Rapid  Return  of  Functions  ....... 

Danger  of  Lumbar  Puncture        ....... 

INDICATIONS,  PROGNOSIS,  DURATION  OF  CURE    . 

Indications  of  Laminectomy  ........ 

Prognosis     ........... 

Statistical  Data         ......... 

Structure  of  Cord  at  Point  of  Compression  ..... 
Duration  of  Cure  ......... 

NEOPLASMATA  OF  THE  VERTEBRAL  COLUMN    . 

Benign  Tumors  ......... 

Observation  XVIII,  1 

Enchondromata  ......... 

Malignant  Tumors     ......... 

Metastases  of  Carcinoma  in  the  Cord  ...... 

Indication  for  Operation    ........ 

Roentgen  Picture       ......... 

Atrophy  of  Vertebral  Bodies       ....... 

SPINAL    PARALYSIS    IN    TUBERCULOSIS    OF   THE 
VERTEBRAL  BODIES  . 

Laminectomy    ....... 

Observation  XVIII,  2 

Extradural  Abscesses  and  Granulations 
ACUTE  OSTEOMYELITIS  OF  THE  VERTEBRAE 
Typhoid  Spondylitis     ...... 

SYPHILIS  AND  ACTINOMYCOSIS  OF  THE  VERTEBRA 

INJURIES  OF  THE  CORD 

Stab  Wounds    ........ 

Gunshot  Wounds        ....... 

Injuries  in  Fractures  and  Dislocations  of  the  Vertebrae 
Bilateral  Luxation  of  Lateral  Articulation  and  Laceration  of 

vertebral  Discs  . 
Fracture  of  Vertebral  Arches 
Regeneration  of  Fibres  of  Cord  . 
Suture  of  Severed  Spinal  Cord  . 
Hemorrhages  into  the  Spinal  Canal 
Haematomyelia 
Indications  for  Laminectomy 


Inter 


76. 


79. 
80. 
81. 
82. 

83. 
84. 

85. 
86. 


92. 

93. 
94- 
95. 
96. 
97. 


Index  of  Figures  in  the  Text  of 
(a)  Volume  II 

A.  BRAIN 

Foci  in  thf  Chimpanzee  ...... 

Sterilizable  Electrode      ....... 

Foci  in  Man  ........ 

68.    Autopsy  Finding  in  the  Brain  of  Observation  I.   1 
Foci  in  Primary  Spasming  Area  in  Observation  I,  2 
71.    Autopsy  Finding  on  the  Brain  of  Observation  I,  2 
Foci  in  Primary  Spasming  Area  of  Observation  I,  3  . 
74.    Autopsy  Finding  on  Brain  of  Observation  1.3. 
Cortical  Defect  After  Extirpation  of  Cortical  Cxlioma  of   the   Anterior 
Central  Convolution        ...... 

Microscopic  Picture  of  a  Cerebral  Scar      .... 

Much  Altered  Capillary  of  the  Anterior  Central  Convolution 
Fibrosarcoma  of  Central  Region        ..... 

Subcortical  Cyst  in  the  Central  Region     .... 

Cortical  Cyst  in  the  Central  Region  .... 

Porencephalitic  Cyst  Beyond  the  Central  Region 

Temperature  and  Pulse  Curve  After  Wide  Opening.     Lateral  Wntric 

Transformed  into  a  Cyst  ..... 
Primary  Spasming  Area  with  Foci  of  Observation,  1.  15  . 
Paralysis  of  Hand  .Vfter  Excision  of   Primary  .Spasming   Centre.      Ob 

servation  I,   10  ...... 

Centres  of  Broca  and  Wernicke         ..... 

Excision   of    Primary    Spasming    Facialis    .ukI    Centre    of    tin-    Hand 

Motor  Aphasia  Following    ..... 
Arachnitis  in  the  Region  of  the  Praecentral  Fissure    . 
91.    V'alve  Formation  in  (ieneral   Epilepsy. 
Exposure  of  the  Central  Region  and  of  a  Traumatic   Cortical  Focus   in 

the  Frontal  Bniin        ...... 

Kocher's  and    KroenUin's   Construction    ... 
Position  of  the  Brain  in  the  Skull    ... 
Scheme  of  Localization  on  the  .Surface  of  the  Brain   . 
Scheme  of  Localization  on  the  Median  Surf.ice  of  the  Brain 
Exposure  of  the  Frontal  Brain  ..... 


22 


Index  of  Figures  in  the  Text 


98.  Suction  of  a  Glioma  of  the  Frontal  Brain 

99,  100.    Glioma  of  the  Frontal  Brain     . 

101.  Sarcoma  of  the  Upper  Central  Region 

102.  Position  of  this  Tumor  in  the  Skull 

103.  The  Principal  Segments  of  the  Internal  Capsule 

104.  Cysticercus  Cysts  at  the  Base  of  the  Brain 

105.  106.    Cysticercus  Cysts  in  the  Substance  of  the  Brain 

107.  Scheme  of  Principal  Tracts  of  Hearing     .... 

108.  Topography  of  the  Tracts  of  Hearing        .... 

109.  Recurrent  Fibrosarcoma  of  the  Region  of  the  Island  of  Reil 

110.  Photographs  of  the  Patient  After  Healing 

111.  Second  Recurrence  in  the  Same  Patient    .... 

112.  113.    Autopsy  Findings  in  the  Brain  of  the  Same  Patient    . 

114.  Horizontal  Scheme  of  Apraxic  Disturbances 

115.  Frontal  Scheme  of  Apraxic  Disturbances  .... 

116.  Fibro-psammo  Sarcoma  in  the  Left  Lower  Parietal  Region 

117.  Exposure  of  the  Occipital  Brain        ..... 

118.  Microscopic  Pictures  of  Fibrosarcoma  of  the  Brain 

119.  Position  of  a  Tumor  of  the  Occipital  Lobe  in  the  Skull 

120.  Temperature  and  Pulse  Curve  in  a  Case  of  "Brain  Fever" 

121.  Scheme  of  the  Visual  Tracts  and  Tracts  of  Pupillary  Reflex 

122.  Horizontal  Section  of  the  Brain  Showing  Visual  Radiation 

123.  124.    Scheme  of  Visual  Field  in  Hemianopsia    . 

125.  Temperature  and  Pulse  Curve  After  a  Cerebellar  Operation 

126.  Cyst  in  the  Vermis  Extending  to  the  Right  Cerebellar  Hemisphi 
127-  Glioma  Sarcomatodes  Cerebelli  with  Cyst  Formation 
128.  Intradural  Exposure  of  the  Posterior  Surface   of   the  Petrous    Portion 

of  the  Temporal  Bone  .... 

129-  Position  of  the  Root  of  the  Acusticus  and  the  Facialis 

130.  Suction  of  a  Tumor  at  the  Cerebello-pontine  Angle  . 

131.  Removal  of  that  Tumor  ...... 

132.  Microscopic  Picture  of  Fibrosarcoma  at  Cerebello-pontine  Angle 

133.  Prolapse  of  the  Brain  After  Removal  of  Tumor  on    Cerebello-pontine 

Angle         ........ 

134.  Endothelioma  of  the  Superior  Vermis         .... 

135.  Exposure  of  this  Tumor  ....... 

136.  Wide  Opening  of  the  Fourth  Ventricle      .... 

137.  Position  of  this  Tumor;  Semischematic  Sagittal  Section 

138.  Tubercle  of  Cerebellum  Adherent  to  the  Dura  . 

139.  Sarcoma  of  the  Gasserian  Ganglion  ..... 

140.  Same  Case.      Excavation  of  Pons  and  the  Medulla  Oblongata 

141.  Sarcoma  of  the  Hypophysis      ...... 

142.  143.    Enormous  Hydrocephalus  ..... 


Index  of  Figures  in  the  Text  28 


(b)  Volume   in 

PIO. 

144.  Kyphosis  of  the  Base  of  the  Skull 

145.  Sngittal  Section  through  thi'  Base  of  the  Normal  .Skull 
1  Mi.    I'l.ip  lM)niiatioii  in  Extnuhiral  Abscess  of  the  Posterior  Surface  of  the 

Petrous  Portion  of  the  Temiwral  Bone 

147.  Microscopic  Picture  of  Metastatic  Carcinoma  of  the  Frontal  I.olii- 

148,  149-    Microscopic  Picture  of   Lymphangioendothelioma 

150.  Exposure  of  Central  Region  in  Open  Injury        .... 

151.  Removal  of  Splinter  of  Bone  from  the  Brain      .... 
15'2-154.    Wanderinji  of  Bullet  in  the  Brain       ..... 

155.  Blade  of   Pocket  Knife  Broken  Otf   and    Remaining    in    thi-    Brain    for 

Fifteen  Years    ........ 

156,  157.    Exposure  and  Removal  of  this  Hladc  .... 


B.  SPINAL  CORD 

158.  Krause's  Laminectome    ......... 

159,  l60.    Removal  of  a  Number  of  \'ertebral  Arches  in  One  Piece 

161.  Horsley's  Cutting  Forceps        ........ 

162,  163.    Rongeur  Forceps     ......... 

164,   165.    SeifFer's  Scheme  of  Segmental  Diagnosis  of  Sensory  Disturbances 
166,   167.    Bing's  Scheme  of  Segmental   Diagnosis  in  Sensory  Disturbances 

168.  Topographic   Relations  of  the  Spinal  Segments  to  the  Bodies  of  the 

Vertebra,  Spinous  Processes  and  Exit  of  Spinal  Roots  . 

169.  Cicatrices  After  Operation  on  the  Cervical  Cord 

170.  Prolapsus  of  Roots  of  the  Cauda  Equina    ..... 

171.  Enchondroma  of  Posterior  Surface  of  Third  Lumbar  Vertebra  (Body 

172.  Zones  of    Hypacsthesia  and  Hyperesthesia  .... 
17.S.    Two  Sarcomata  on  the  Outer  Surface  of  the  Dura 

174.  Exposed   Dura  of   the  Cervical   Cord   in  the   Depth   of   a   CJranulating 

Cavity        ......... 

175.  Scar  After  Healing  of  that  Cavity    ...... 

176.  Constriction  of  Thoracic  Cord  .  ...... 

177.  Focus  of  Softening  in  the  Thoracic  Cord  ..... 

178.  Cheesy  Sequestrum  in  the  Induration  of  the  Thoracic  Cord 

179.  Sarcoma  of  the  Bodies  of  the  N'ertelmr      ..... 

180.  Roentgen  Ray  Picture  of   a  -Sarcoma  of   the   Bodies  of   thi-    Thinl   .11 

Fourth  Cervical  Wrtebric    ...... 

ISl.    Tuberculous  Siiondylitis  of  the  Upjjcr  Thoracic  Portion  of  the   \'irt 

bral  Cohnnn:  .Sagittal  Section      .... 

182.    .Sagittal  Section  of  a  Similar  Case    ...... 

18.'f.    Illustrations  After  Healing       ....... 

184.    Luxation  Fracture  of  thv  Eighth  Intervertebral  Disc  with  Penetrating 

Injury  of  the  Thoracic  Cord  ..... 


Index  of  Plates  in 
(a)  Volume  11 


PLATE 

XXVI. 


XXVII. 


A.  BRAIN 

Fig.  a.    Focus  in  Primary  Spasming  Area.      Observation  I,   1    . 

Fig.  2.  Markedly  CEdematous  Arachnoidea.  Bulging  in  the 
Form  of  a  Tensely  Filled  Bag  After  Opening  of  the 
Dura.  Field  of  Operation  Rendered  Bloodless  by 
Deligations.      Observation  I,  3       . 

Leptomeningitis  Levis  in  Jacksonian  Epilepsy.      Foci  and  Ex 
cision  of  Centre     ....... 

XXVIII.      Microscopic  Changes  in  Cortex  in  Jacksonian  Epilepsy     . 
XXIX.      Fig.  a.    Multilocular  Cyst  in  the  Upper  Portion  of  the  Central 
Region.      Observation  I,  9     ■ 
Fig.  b.    Porencephalitic   Cyst    Below   the    Facial    Centre    (s) 
Excision   of  the  Centres  of  the  Hand  and  Forearm 
(l,  2,  3,  4).      Observation  I,  10  . 

XXX.  Fig.  a-  Severe  Changes  in  the  Central  Region  After  Forceps 
Delivery.  Large  Cortical  and  Small  Subcortical 
Cyst.  Atrophy  of  the  Cortex.  Excision  of  the 
Primary  Spasm  Centre  of  the  Hand  and  the  Forearm. 
1,  2,  3  represent  the  Foci  of  these  Members  Ascer- 
tained by  Faradism  (Unipolar).  Observation  I,  13 
Fig.  b.  Changes  in  the  Central  Region  Following  Meningo- 
encephalitis.     Observation  I,  14    . 

XXXI.     Very  Marked  Bulging  of  the  Brain  in  the  Status  Epilecticus. 
Observation  I,  18 

XXXII.  Traumatic  Defect  in  the  Frontal  Brain.  Dura  and  Arachnoid 
Covering  It  Very  Thickened  and  Adherent  (indurated 
Scar).      Observation  I,  20      .  .  .  . 

XXXIII.  Trephining    Over   the  Left    Cerebellum.       Slight    Findings. 

Tumor  in  Right  Frontal  Pole.      Observation  II,  3    . 

XXXIV.  Sarcoma  in  the  Upper  Portion  of  the  Central  Region.      Adher- 

ent to  the  Dura.     Lamina  Vitrea  Strongly  Changed.     Ob- 
servation III,  4     ...••••  • 
'  24 


Indkx  of  Plates  25 

PLATE  PACE 

XXXV.      Nt'oplasm  of  Posti-rior  Central  Convolution.      Observation  III,  5 

XXXV'I.       I""il)rosarc()nia  in  the  Upper  Central  Hefiion.      Observation  III,  8 

XXXVII.       Fiji.   II.    Solitary  Tiiberele  of  Itifrllt  Cerclirll.ir   II. mispliere  and 

at  the  Base  of  the  Brain  ..... 

Fig.   /;.    Neoplasm   of   the   Corpus    (^uadrimniiniini    Below    the 

Splenium  Corporis  Callosi      ..... 

XXXX'III.      Symptoms  of  Acusticus  Tumor.      Large  Neoi)lasm  at  the  Base 
of  the  Br.iin.       Observation  \III.    1  .  .  .  . 

XXXIX.      Cysticereus  Uaeemosus  at  the  Basis  of  the  Brain.      Observation 
Vlll.  .5 

XL.      Exposure  of  the  Medulla  Oblongata        ..... 


(b)   Volume  III 


XLL      Extirpation  of  the  Gasserian  Cianglion   ..... 

XLII.      Sarcoma     of     the    Gasserian   Ganglion.       Observation    IX,     1 

XLIIl.      Fig.  a.      Knife    Blade    in    Frontal    Lobe.     Observation    X,     1 

Fig.  /).      Otitic  Abscess  of  Temporal  Lobe     .... 

XLI\'.      Fig.  a.    Multiple  Abscesses  of  the  Temporal   Lobe.      Observa- 
tion X,  5    . 
Fig.  b.    Rhinitic  Abscess.      Observation  X,   13 
XLV.      Meningitis  Puruk'nta  ex  Otitide.      Observation  X,    1  4-      . 

XLVI.      Carcinoma  Metastasis  in  the  Frontal   Brain   Following   Primary 
Carcinomatous  Invasion  of  the  Breast.      Obserration  XI,   1 

XL\'II.      Figs,  n  and  A.    Metastatic  Carcinoma  of  the  Dura  Mater.      Ob- 
servation XI,  4     . 
Fig.  c.    Multiph'   Endotheliomata  of    the   Brain.      01)servation 
XI,  .S 

B.  SPINAL  CORD 

XLV'III.    Fig.  a.    P.sammoma  of  the  Dura  at  the  Level  of  the  Arch  of  the 

Seventh    Thoracic  Vertebra.      Observation    XIII,    1 

Fig.   /).    Fibrosarcoma  of   the  Dura   at    Level  of    .Sixth  Cervical 

Vertebra  (Arch)  ....... 

XLIX.       Fibrosarcoma  of  .Spinal  Membranes  at  Second  and  Third  .Vrehes 
of  Cervical  Vertebra.      Observation  XIll.  v! 


26  Index  of  Plates 

PLATE  PAGE 

L.  Fibrosarcoma  of  the  Arachnoid,  Rich  in  Cellular  Elements. 
Level  of  Arches  of  Sixth  and  Seventh  Cervical  Vertebra. 
Observation  XIII,  3 

LI.  iSIyxosarcoma  of  the  Arachnoid  at  Level  of  Arches  of  Fourth 
to    Seventh   Cervical   Vertebrae.       Observation  XI,    4 

LII.      Fig.  a-    Angiosarcoma   of   the   Soft    Coverings    of    the    Cord 
Lumbar  and  Sacral  Segment.       Observation  XIII,  6 
Figs,  b,  c,  d.   Arachnitis   Fibrosa  with  Stagnation   of  Liquor 
Observation  XIV,   1       ....  . 

LIII.      Arachnitis  Adhaesiva.      Observation  XIV,  2   . 

LIV.      Figs,  a,  h-   Extradural  Exostosis    on  the  Body  of  the  Fourth 
Lumbar  Vertebra.      Observation  XIV,  5 
Fig.  c.    Intramedullary     Neoplasm     (?)     with     Stagnation    of 
Liquor.      Observation  XIV,  7 

LV.  and  LVI.  Suppurative  Necrotic  Process  in  the  Arch  of  Fifth 
Cervical  Vertebra  with  Secondary  Meningitis  Serosa 
Observation  XIV,   10 

LVII.      Induration  of  Thoracic  Cord.      Observation  XV,  2 

LVIII.      Induration  of  Thoracic  Cord.      Opening  of  Cyst  in  the  Medul 
lary  Substance.      Observation  XV,  3        .  .  . 

LIX.      Tuberculous   Induration  of    the   Dura    in  the   Thoracic  Cord 
Observation  XV,  4         .....  . 

LX.      Angioma  Venosum   Racemosum  of  the   Arachnoid  and  Pia 

LXI.      Solitary  Tubercle  with  Arachnitis  Tuberculosa  in  Upper  Tho 
racic  Cord.      Observation  XVI,  2    . 

LXII.      Enchondroma   of     Cervical    Vertebra     (Body).       Observation 
XVIII,  1 


IMPORTANT  TO  THE   NEUROLOGIST: 

BELOUSOW — Synoptical   Delineation  of  the  Nerves  of  the  Human   Body. 

By  A.  K.  Hki.ol'sovv,  Professor  of  Anatomy  at  the  University  of  Cliarkow 
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versity of  Basle.     Translated  by  F.  S.  Arnold,  B.A.,  M.B.,  B.Ch.   (C)xon). 
Revised  by  David  I.  Wolfstein. 

This  is  a  practical  working  guide,  intended  to  present  no  elaborate  theories  or 
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HILQER — Hypnosis  and   Suggestion.     Their  nattire,   action,   importance  and 
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Translated  by   R.   W.   Fi-:lkin,   M.D.,   F.R.S.E.     With   an   Introduction   by 
Dr.  V.\n  RentergheiM    (Amsterdam).     Translated  by  A.  Newbold. 
242  pages.     Cloth.     Price,  $2.50. 

HOLLANDER — Brain    Disease    (the   Mental   Symptoms   of).     An  Aid  to  the 

Surgical  Treatment  of  Insanity,  due  to  Injury,   Hemorrhage,  Tumors  and 

Other  Circumscribed  Lesions  of  the  Brain.    By  Bern.^rd  Holl.\nder,  M.D., 

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237  pages.     Cloth.     Price,  $2.00. 

TANZI — A  Textbook  of  Mental  Diseases.  Bv  Eugenic  T.vnzi,  Professor  of 
Psychiatry  in  the  Royal  Institute  of  Higher  Studies  of  Florence.  Author- 
ized translation  froin  the  Italian  by  \\'.  Ford  Robertson,  M.D.,  C.^L, 
Pathologist  to  the  Scottish  Asylums,  Edinburgh ;  Member  of  the  Medico- 
Psychological  Association  of  Great  Britain  and  Ireland ;  Foreign  ^Member 
of  the  Societa  Freniatrica  Italiana,  Author  of  "A  Textbook  of  Pathology 
in  Relation  to  Mental  Diseases,"  and  T.  C.  M.^ckenzie,  M.D.,  F.R.C.P., 
Edinburgh,  Medical  Superintendent  Inverness  District  Asylum;  Member 
of  the  Medico-Psychological  Association  of  Great  Britain  and   Ireland. 

"To  the  American  reader  the  chapter  on  pellagra  is  of  great  interest,  and  at  once 
brings  up  the  question  of  how  much  of  the  insanity  among  Italian  immigrants,  to- 
gether with  many  obscure  forms  of  spinal  disease,  may  possibly  be  due  to  pellagra." — 
New  York  Medical  Journal. 

820  pages,  1.32  Illustrations.     Cloth.     Price,  $7.00. 

REBMAN    COMPANY,    1123  Broadway,  New  York  City. 


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